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DISEASES 


OF  THE 


DIGESTIVE    CANAL 

(CESOPHAGUS,  STOMACH,  INTESTINES) 


BY 

Dr.  PAUL  COHNHEIM 

SPECIALIST    IN    DISEASES    OF    THE    STOMACH    AND    INTESTINES    IN    BERLIN 


FROM  THE  SECOND  GERMAN  EDITION 

EDITED  AND  TRANSLATED 
BY 

DUDLEY  FULTON,  M.D. 

LECTURER   ON    MEDICINE,    UNIVERSITY    OF    SOUTHERN    CALIFORNIA,    LOS    ANGELES 


ILLUSTRATED 


PHILADELPHIA  ^^  LONDON 

J.   B.  LIPPINCOTT    COMPANY 


CoPYKiGnx,  1909 
By  J.  B.  LippiNCOTT  Company 


Printed  by  J.  B.  Lippincotl  Company 
Tlie  Waslmipton  Square  Press,  Philadelphia,    V.  S.  A. 


DEDICATED 
TO  HIS  HIGHLY  ESTEEMED  TEACHER 

Professor  Dr.  I.  BOAS 

OF   BERLIN 

WITH  THE  GRATITUDE  OF 
THE  AUTHOR 


TRANSLATOR'S   PREFACE 

Perhaps  the  most  distinctive  feature  of  the  present 
volume  is  the  discussion  of  the  subject-matter  purely  from  the 
clinical  point  of  view. 

Dr.  Cohnheim  considers  the  anamnesis  the  most  impor- 
tant part  of  the  examination  in  the  diagnosis  of  diseases  of 
the  gastro-intestinal  canal;  and  throughout  the  volume  he 
so  defines  the  significance  of  subjective  symptoms  that  the 
reader  will  scarcely  fail  to  be  impressed  with  the  value  of  the 
art  of  interpreting  these  rather  than  applying  himself  to 
complicated  details  of  laboratory  work. 

The  author  frankly  disclaims  any  attempt  to  review  the 
literature,  or  to  compile  the  views  of  others,  or  to  present  any 
pathological  details  and  theoretical  discussions;  every  subject 
is  attacked  with  directness  and  all  non-essentials  are  ignored. 
The  volume  is,  in  fact,  a  succinct  record  of  his  everyday 
experience  with  gastro-intestinal  diseases  of  every  kind,  and 
this  is  perhaps  the  most  valuable  asset  of  the  book. 

Those  who  have  attended  Dr.  Cohnheim's  clinic  know 
quite  well  that  he  has  no  hesitation  in  dissenting  from  con- 
ventional theories  which  have  not  proven  successful  in  practice. 

All  of  the  above-described  features  are  strongly  presented 
in  the  German  editions,  and  I  have  endeavored  to  preserve 
them  intact  in  the  Enghsh  version;  in  order  to  retain  this 
characteristic  quality,  I  have  made  but  few  editorial  emenda- 
tions, all  such  data  being  enclosed  in  brackets. 

I  wish  to  thank  the  publishers  for  their  unfaiUng  courtesy, 

Mr.  W.  Halven  and  Miss  Ruby  Archer  for  their  assistance  in 

the  preparation  of  the  manuscript,  Dr.  Malcolm  Lloyd  for  the 

drawings  which  have  been  added  to  the  English  edition,  and 

Mr.  Leroy  Baumberger  for  his  careful  stenographic  work  and 

preparation  of  the  index. 

Dudley  Fulton,  M.D. 

Los  Angeles,  December^  1908. 


PREFACE  TO  THE  ENGLISH  EDITION 

Since  the  first  German  edition  of  this  medical  work 
made  its  appearance,  many  American  and  EngHsh  physicians 
who  attended  my  cKnic,  but  who  were  not  sufficiently  con- 
versant with  the  German  language  to  understand  all  the 
details,  have  repeatedly  expressed  the  wish  that  an  English 
edition  of  my  work  be  published. 

I  have  finally  decided  to  act  upon  this  suggestion,  and 
am  especially  willing  to  do  so  at  this  time  for  the  reason  that 
my  esteemed  colleague,  Dr.  Dudley  Fulton,  of  Los  Angeles, — 
who  has  studied  the  modern  methods  of  diagnosis  and  thera- 
peutics of  the  diseases  of  digestion  in  my  polycHnic  and  is 
thoroughly  familiar  with  the  principles  upon  which  my  book 
is  based, — consents  to  prepare  the  English  edition. 

I  gladly  authorize  him  to  do  so,  and  am  exceedingly 
obliged  to  him,  as  well  as  to  the  publishers,  the  J.  B.  Lippincott 
Company,  of  Philadelphia,  for  their  manifold  courtesies. 

Encouraged  by  many  cordial  expressions  of  English- 
speaking  friends,  the  author  trusts  that  the  present  edition 
will  supply  a  need  of  the  general  practitioner,  and  that  it 
will  find  a  friendly  reception  and  kind   criticism  among  its 

new  circle  of  readers. 

Paul  Cohnheim. 

Berlin,  February  16th,  1908. 


PREFACE  TO  THE  SECOND  GERMAN 
EDITION 

The  demand  for  a  new  edition  of  this  work, — after  scarcely 
two  years  have  elapsed, — is  evidence,  I  believe,  of  its  friendly 
reception  by  the  profession. 

The  medical  press  has  criticized  my  book  in  a  favorable 
way,  and  has  given  me  helpful  hints  for  improvement  in  the 
second  edition. 

To  all  kind  censors,  many  thanks! 

I  am  especially  grateful  to  all  that  have  assisted  me  by 
suggesting  recent  developments  in  the  knowledge  of  digestive 
disorders;  and  I  desire  to  thank  particularly  my  fellow 
specialists.  Dr.  F.  Hoppe,  of  Hanover,  and  Dr.  F.  Ehrlich,  of 
Stettin. 

The  general  plan  and  arrangement  of  the  book,  and  the 
restriction  of  its  contents  to  a  consideration  of  only  practical 
measures,  remain  unaltered.  I  have  merely  added  some  of  the 
newer  diagnostic  and  therapeutic  methods,  and  with  these 
changes  I  present  the  second  edition  to  the  profession. 

Paul  Cohnheim. 

Berlin,  September  1st,  1907. 


PREFACE  TO  THE  FIRST  GERMAN 
EDITION 

In  compliance  with  the  urgent  desire  of  my  students,  I 
have  finally  decided  to  publish  the  present  volume.  My 
hesitation  will  be  understood  when  one  considers  the  numerous 
well-known  text-books  available  on  stomach  and  intestinal 
diseases.  But  as  my  little  book  contains  the  essence  of  what 
I  have  used  for  years  in  presenting  and  demonstrating  patients 
and  specimens  to  physicians  attending  my  polyclinic,  it  offers 
only   the   practical   points    of   view. 

In  order  that  it  might  not  be  over-burdened,  I  have 
been  obliged  to  exclude  physiological,  pathological,  and 
anatomical  subject-matter,  as  well  as  frequent  reference 
to  the  literature.  Since  this  book  is  intended  for  the  use 
of  the  general  practitioner,  I  believe  I  am  justified  in  having 
done  so. 

With  the  same  object  in  view,  everything  has  been  omitted 
that  could  be  spared  in  the  clinical  portion  of  the  book. 

At  the  outset,  I  wish  to  defend  myself  against  any  suppo- 
sition that  the  present  volume  is  a  compilation  from  other 
text-books,  and  I  beg  leave  to  emphasize  the  fact  that  it 
contains  the  record  of  personal  experience  during  my  many 
years  of  work  as  the  assistant  of  Dr.  I.  Boas,  whom  I  desire 
to  thank  publicly  for  his  aid  and  scientific  guidance.  The 
book  likewise  includes  knowledge  gained  in  my  private  and 
polyclinic  experience;  and  since  my  practice  has  always  been 
a  general  one,  it  has  made  me  familiar  with  those  points  that 
are  essential  to  the  general  practitioner,  and,  therefore,  to 
be  dealt  with  in  such  a  work. 

Although  the  reading  of  any  treatise  can  scarcely  replace 
the  advantages  of  clinical  instruction  and  laboratory  demon- 
strations, yet  I  believe  that  this  manual  will  be  a  trustworthy 


xii     PREFACE  TO  THE  FIRST  GERMAN  EDITION 

guide  to  the  physician  in  the  difficulties  of  diagnosis  and  treat- 
ment of  diseases  of  digestion.  With  this  desire  I  offer  it  to  the 
public,  and  hope  for  a  kind  reception  on  the  part  of  its  readers. 
I  owe  the  execution  of  the  microscopical  drawings  to  the 
kindness  of  Miss  Paula  Guenther. 

Paul  Cohnheim. 

Berlin   May  Lst,  1905. 


TABLE  OF  CONTENTS 


GENERAL  SECTION 

PAGE 

Anamnesis  and  Subjective  Symptomatology 1 

Physical  Examination 5 

Inspection 5 

Percussion 8 

Palpation 8 

Auscultation 21 

Internal  Chemical  and  Microscopical  Examination  of  the  Stomach.  .  21 

Introductory  Remarks 21 

Qualitative  Examination 23 

Quantitative  Examination 25 

Ferment  Tests 29 

Motility  Tests 35 

Jlicroscopical  Examination  of  the  Stomach-contents 36 

Examination  for  Blood 41 

Technic,    Indications    .\nd    Contraindications    in    the    Use    of   the 

Stomach-Tube 42 

Laboratory  Apparatus 46 


SPECIAL  SECTION 

Diseases  of  the  CEsophagus 48 

Cancer  of  the  (Esophagus 48 

Ulcer  of  the  (Esophagus 50 

Benign  Stenosis  (including  Strictures  and  Spasms) 57 

Dilatation  of  the  (Esophagus  (Diverticulum) , 60 

Chronic   Cardiospasm 61 

Foreign  Bodies 67 

Neuroses  of  the  CEsophagus 68 

Diseases  of  the  Stomach 71 

Clinical  Remarks 71 

Organic  Diseases  of  the  Stomach 82 

Acute  and  Chronic  Gastric  Catarrh 82 

Acute  Gastritis  83 

Chronic  Gastritis 87 

Ulcer  of  the  Stomach^ 108 

Appendix:  Erosions  and  Fissures  of  the  Pylorus 127 

Carcinoma  of  the  Stomach 133 

xiii 


xiv  TABLE  OF  CONTENTS 

PAGE 

Diseases  of  the  Stomach:    Organic  (Continued) 

Epigastric  Hernia 150 

Gastrectasis 151 

Perigastritis 167 

Hypersecretion 168 

Hyperchlorhydria 172 

Functional  Diseases  of  the  Stomach 177 

Ana^mic-Gastroptotic  Dyspepsia  (Atony) 180 

Remarks  on  Enteroptosis 190 

Phthisical  D3'spepsia 196 

Nervous  Dyspepsia 199 

Special  Forms  of  Neuroses  of  the  Stomach 209 

Diseases  of  the  Stomach  in  Connection  with  Diseases  of  Other  Organs.  223 

The  Stomach  and  Disorders  of  Metabolism 223 

Acute  and  Chronic  Infectious  Diseases 225 

Central  Nervous  System 225 

Stomach  and  Circulatory  System 228 

Stomach  and  Diseases  of  tlie  Lungs 229 

Stomach  and  Genito-urinary  Apparatus 230 

Stomach  and  Liver,  Pancreas  and  Spleen  [Gail-Bladder] 231 

Stomach  and  Intestinal  Diseases 235 

Stomach  and  Sexual  Organs 236 

Diseases  of  the  Intestine 237 

Introduction 237 

Examination  of  the  Patient 242 

Chemical  and  Microscopical  Examination  of  the  Stool 245 

Primary  Organic  Diseases  of  the  Intestine 253 

Acute  Enteritis 253 

Chronic  Catarrh  of  the  Intestine 257 

Appendix:  Membranous  Enteritis,  Meteorism  and  Flatulence.  265 

Ulceration  of  the  Mucous  Membrane  of  the  Intestine 271 

Typhlitis  and  Appendicitis 275 

Tumors  and  Neoplasms  of  the  Intestine 281 

Displacements  of  the  Intestine 283 

Secondary  Organic  Diseases  of  the  Intestine 285 

Stenosis  and  Dilatation  of  the  Intestinal  Canal 285 

Intestinal  Obstruction 289 

Acute  and  Chronic  Peritonitis 294 

Functional  Diseases  of  the  Intestine 299 

Chronic  Constipation 299 

Appendix:  Relationship  between  Constipation  and  Diarrhoea.  318 

Neuroses  of  the  Intestine 319 

Atony  of  the  Intestine 321 

Intestinal  Spasms  (Lead  Colic) 321 

Nervous  Diarrhoea .  323 

Peristaltic  Unrest  of  the  Intestine 323 

Intestinal  Neurasthenia 324 

Intestinal  Disturbances  in  Diseases  of  Other  Organs 325 


TABLE  OF  CONTENTS  xv 

PAGE 

Diseases  of  the  Intestine:   Functional  (Continued) 

Parasites  of  the  Intestine 325 

Diseases  of  the  Rectum 330 

Catarrh  and  Inflammation  of  the  Rectum 331 

Ulceration  of  the  Rectum 334 

Fissures  and  Erosions  of  the  Anus 335 

Neoplasms  of  the  Rectum 337 

Hemorrhoids 337 

Malignant  Neoplasms  of  the  Rectum 341 

Benign  Stenoses  of  the  Rectum 344 

Nervous  Diseases  of  the  Rectum 345 

Appendix 347 

Diagnostic  Table '. 347 

Outline  of  Dietetic  Treatment 348 

Outline  of  Balneotherapy 356 

Indications  for   Hydrotherapeutic,   Mechanical    and    Electrical  Treat- 
ment    359 

Clinical  A  B  C  of  the  Most  Important  Disturbances  of  the  Digestive 

Tract 361 

Index 367 


LIST  OF  ILLUSTRATIONS 


FIG.  PAGE 

1 .  (A)  Diagram  of  normal  habitus 6 

2.  (B)  Diagram  of  habitus  enteropticus 6 

3.  Palpation  of  the  abdomen 10 

4.  Obrastzow's  palpatory  percussion  method  for  determining  the  borders 

of  the  stomach 12 

5.  Palpation  of  the  right  kidney 15 

6.  Typical  pressure  point  in  gastric  ulcer 17 

7.  Typical  pressure  zone  in  liver  and  gall-bladder  affections 18 

8.  Pressure  areas  in  nervous  affections  of  the  stomach 19 

9.  Separating  apparatus  suitable  for  making  test  for  lactic  acid  (Strauss 's)  24 

10.  Microscopic   findings  from   fasting   stomach  containing   free    HCl,  but 

no  food  remnants 37 

11.  Microscopic   findings    from  fasting    stomach   containing   neither    HCl 

nor  food 38 

12.  Microscopic  findings  from    fasting    stomach  which  contains  both    HCl 

and  food 39 

13.  Microscopic   findings   from   fasting   stomach  which   contains   food  and 

lactic  acid  but  no  HCl 40 

14.  (A)  American  stomach-tube;  (B)  Riegel's  stomach-tube 43 

15.  (A)  Modified  Jacques  stomach- tube ;  (B)  Ewald's  stomach-tube 44 

16.  Method  of  introducing  the  stomach-tube 45 

17.  Trousseau's  oesophageal  bougie 50 

18.  Cardiospasm  dilator  and  mercurial  manometer 64 

19.  1.  Obturator;    2.   CEsophagoscope;     3.   Coin  catcher  and  foreign-body 

forceps 68 

20.  Diagram  showing  different  positions  of  the  stomach 73 

21.  Normal  mucous  membrane  of  the  stomach  (pylorus) 88 

22.  Mucous  membrane  in  interstitial  and  atrophic  gastritis  (alcoholic) 88 

23.  Diagram  showing  the  development  of  the  various  forms  of  gastritis.  ...  89 

24.  Typical  pressure  point  in  gastric  ulcer 114 

25.  Hour-glass  contraction  of  the  stomach,  cicatricial  stenosis  of  the  pylorus 

and  cardia  with  a  dilatation  of  the  oesophagus 118 

26.  Carcinomatous  degeneration  of  an  ulcer  of  the  pylorus 134 

27.  Diagram  showing  the  development  and  progress  of  cancer  of  the  stomach  138 

28.  Cancer  of  the  cardia  producing  stenosis 142 

29.  Gastrectasia  secondary  to  ulcer  of  the  pylorus 157 

30.  Diagram  showing  the  development  and  course  of  hypersecretion 169 

31    to  33.  Various  forms  of  abdominal  belts 192 

34.  Stengel's  kidney  belt 192 

x\ai 


xviii  LIST  OF    ILLUSTRATIONS 

FIG.  PAGE 

35.  Diagram  of  Rose's  adhesive  plaster  belt  marked  for  cutting 193 

36.  Diagram  of  Rose's  adhesive  plaster  belt 193 

37.  First  step  in  the  application  of  the  adhesive  plaster  belt 194 

38.  Second  step  in  the  application  of  the  adhesive  plaster  belt 195 

39.  Microscopic  findings  of  the  normal  stool 247 

40.  Microscopic  findings  of  a  stool  containing  bismuth,  fat-cells,  etc 248 

41.  Microscopic  findings  of  the  stool  in  enteritis 249 

42.  ^licroscopic    findings    in    a    stool    containing    taenia    solium,    eggs    of 

ascarides,  Charcot-Leyden  crystals,  etc 250 

43.  Ulcer  of  the  duodenum 273 

44.  Rectal  irrigator  (Strauss) 333 

45.  Tuttle's  rectoscope 334 


INTRODUCTION 

A  BOOK,  to  be  a  practical  guide  for  the  physician  in  the 
diagnosis  and  therapy  of  stomach  and  intestinal  diseases, 
must  avoid  complicated  methods  which  require  special  experi- 
ence and  the  apparatus  of  a  laboratory. 

I  have,  therefore,  laid  the  greatest  stress  upon  a  thorough 
and  rational  anamnesis  in  making  the  examination.  The 
varying  complaints  and  discomforts  of  patients,  as  well  as 
the  symptoms  of  the  different  forms  of  dyspepsia,  are  modi- 
fied so  largely  by  rest,  exercise  and  occupation,  by  the  amount 
and  character  of  the  food,  and  by  the  condition  of  the  bowels, 
that  the  skilled  examiner  will  be  able  to  form  a  correct  diag- 
nosis in  most  cases  from  the  answers  to  his  questions.  For 
this  reason,  I  cannot  sufficiently  emphasize  the  need  of  mak- 
ing a  provisional  diagnosis  while  obtaining  the  history  of  the 
patient,  which  the  physical,  chemical  and  microscopical 
findings  will  either  confirm  or  reject. 

When  considered  alone,  the  physical  findings  are  far 
more  liable  than  the  clinical  history  to  mislead  one  in  making 
the  diagnosis.  For  example,  the  diagnosis  of  ''dilatation  of 
the  stomach"  is  frequently  made  when  the  greater  curvature 
of  the  stomach  is  found  to  be  below  the  umbilicus.  Now, 
since  vomiting  is  never  absent  in  actual  dilatation  of 
the  stomach,  and  the  history  of  the  patient  would  establish 
the  presence  or  the  absence  of  this  symptom,  a  careful  anam- 
nesis would  thus  prevent  this  wrong  diagnosis. 

I  have  been  very  careful,  throughout,  to  emphasize  the 
difference  between  organic,  or  anatomical,  and  functional,  or 
nervous,  stomach  and  intestinal  diseases.  All  other  points 
are  of  lesser  importance  in  comparison  with  this  cardinal 
information,  since  the  accuracy  of  this  knowledge  determines 
the  therapy.  Organic,  or  anatomical,  stomach  and  intestinal 
diseases  require  local  treatment;   while  functional,  or  nervous, 


XX  INTRODUCTION 

secondary,  or  reflex,  stomach  and  intestinal  affections,  which 
are  s3'mptoms  of  some  constitutional  disorder,  or  are  second- 
ar)^  to  a  disease  of  some  other  organ,  are  to  be  treated  with 
reference  to  the  primary  cause. 

I  shall  give  only  one  example:  Phthisis  produces  very 
often,  at  first,  a  loss  of  appetite  and  pressure  in  the  stomach, 
which  arc  frequently  attributed  to  chronic  catarrh  of  the 
stomach;  and  such  patients  are  often  prescribed  a  liquid 
diet  for  a  long  period,  in  the  supposition  that  an  organic 
stomach  trouble  exists;  when,  in  fact,  only  the  treatment  of 
the  primar}^  disease, — in  this  case,  phthisis, — would  cause  a 
disappearance  of  the  symptoms  of  dyspepsia. 

It  is  appropriate  to  mention  in  this  place  that  persons 
afflicted  with  lung,  heart,  kidney,  liver  and  nervous  disorders 
are  very  frequentl}^  sent  to  the  specialist  for  treatment  of 
dyspepsia. 

The  examiner  must,  therefore,  in  every  case  of  stomach 
or  intestinal  disease,  make  it  his  absolute  duty  to  examine 
all  the  internal  organs  and  also  the  central  nervous  S3'stem. 

The  epigastrium,  with  its  numerous  sympathetic  nerve- 
ganglia,  offers  a  focus  toward  which  the  diseases  of  all  possible 
organs  throw  their  rays.  This  explains  the  fact,  not  com- 
monly known,  that  a  large  percentage  of  ''stomach  troubles" 
are  of  a  functional  nature;  and  therein  is  found  the  explana- 
tion of  the  surprising  truth  that  a  great  many  patients  suffer- 
ing from  chronic  stomach  trouble  obtain  relief  through 
"quacks,"  after  having  vainl}"  sought  relief  for  years  in  the 
regular  schools  of  medicine.  Indeed,  the  physician  who, 
in  clinical  instruction  in  the  universities,  comes  in  con- 
tact with  organic  maladies  almost  exclusively,  is  naturally 
inclined  to  consider  most  stomach  and  intestinal  affections 
as  organic. 

Stomach  pathology,  more  than  any  other  department  of 
medicine,  shows  the  influence  of  bad  habits,  excesses  "in 
Baccho  et  Venere,"  non-hygienic  living,  worry,  anxiety  and 
the  restless  haste  and  strenuousness  of  modern  business  life. 
In   every   rational   therapy,   therefore,   it   is   of   the   greatest 


INTRODUCTION  xxi 

importance  to  establish  the  cause  of  the  dyspepsia  by  investi- 
gating the  occupation,  home  environment,  habits,  diet,  and 
general  physical  condition  of  the  patient. 

An  exact  anamnesis  is  always  the  most  difficult  and 
prolonged  and  also  the  most  important  part  of  the  examina- 
tion, because  the  clews  thus  obtained  furnish  not  only  the 
best  fulcrum  for  the  diagnosis,  but  also  the  best  indication 
as  to  the  causal  therapy. 

The  contents  of  the  book  are  arranged  in  the  following 
manner : 

In  the  General  Section  on  Stomach  Diseases  tliese  topics 
are  considered: 

1.  The   anamnesis,    with  the   different   subjective   symp- 

toms; 

2.  The    methods    of    physical    examination,    particularly 

palpation; 

3.  The  chemical  and  microscopical  methods  of  examina- 

tion. 

The  Special  Section  on  Stomach  Diseases  is  divided  into 
three  parts: 

1.  The  organic,  or  anatomical,  local  diseases; 

2.  The  functional  disorders,  or  atony,  neuroses,  etc.; 

3.  The    symptomatic    stomach    disorders,    secondary    to 

diseases  of  other  organs. 

The  same  arrangement  is  employed  in  the  Section  on 
Intestinal  Diseases,  except  that  the  presentation  is  much 
shorter,  in  order  to  avoid  repetition. 

In  the  beginning  of  the  Special  Section  on  Stomach 
Diseases,  I  have  given  a  short  abstract  on  the  Diagnosis  and 
Therapeutics  of  Diseases  of  the  Oesophagus. 

As  an  appendix,  I  have  added  a  diagnostic  and  thera- 
peutic glossary,  which  will  be  convenient  for  the  practitioner. 

At  the  end  of  the  book  are  outlines  of  balneotherapy, 
electrotherapy,  diet,  etc.,  appropriate  to  our  subject. 


DISEASES 


OF  THE 


DIGESTIVE  CANAL 


GENERAL   SECTION 

Anamnesis  and  Subjective  Symptomatology 

Patients  are  unable  to  differentiate  between  the  important 
and  the  unimportant  symptoms  of  disease.  Therefore,  in  ob- 
taining the  history  of  a  gastro-intestinal  affection,  it  is  essential 
that  the  physician  should  not  allow  the  patient  to  enumerate 
aimlessly  all  his  subjective  disturbances,  but  should  require 
him  to  give  short,  precise  answers  to  the  following  questions: 

1.  How    long    have    you    been    ill? 

Indefinite  statements,  such  as  "'A  long  time,"  or  ''Several 
months,"  are  without  value.  The  physician  must  ascertain 
exactly  how  many  weeks,  months,  or  years  the  patient  has 
suffered  from  indigestion,  when  the  symptoms  first  appeared, 
whether  the  trouble  developed  suddenly  or  gradually,  and 
whether  the  disease  has  been  intermittent  or  progressive. 

The  information  derived  from  these  answers  immediately 
enables  him  to  differentiate  acute  from  chronic  affections. 

2.  Do  you  suffer  constantly  or  only 
occasionally? 

This  question  is  important,  because  the  course  and  pro- 
gress of  the  disorder,  and  the  variations  of  its  intensity,  are 
significant  in  every  primary  disease  of  the  stomach  and  intes- 

1 


2  DISEASES  OF  THE  DIGESTIVE  CANAL 

tine.  For  example,  gastric  pains  which  occur  periodically  are 
typical  of  peptic  ulcer  or  of  the  gastric  crises  of  tabes,  etc.; 
while,  on  the  other  hand,  sA'mptoms  which  are  constant  are 
characteristic  of  chronic  gastritis,  nervous  dyspepsia,  etc. 

It  is  especially  necessary  to  determine  whether  periods 
of  normal  digestion  have  alternated  with  periods  of  dyspepsia. 

3.  Can  you  s  w  a  1  1  o  \^•  all  kinds  of  food 
w  i  t  h  o  u  t    d  i  f  f  i  c  u  1  t  y  ? 

With  this  ciuestion,  the  physician  begins  the  incjuiry 
concerning  the  symptoms  pertaining  to  diseases  of  the  different 
portions  of  the  digestive  tract. 

If  the  patient  answers  this  question  in  the  negative,  some 
affection  of  the  oesophagus  exists.  More  detailed  questions 
will  determine  whether  solids  only  are  swallowed  with  diffi- 
culty, whether  such  are  vomited,  and  whether  the  impediment 
to  deglutition  is  constant  or  periodical.  (See  details  in  special 
chapter  on  Diseases  of  the  Qilsophagus.) 

4.  Have  you  actual  pain  or  only  pres- 
sure? 

This  question  is  of  the  greatest  possible  significance, 
because  a  purely  functional  dyspepsia  never  causes  actual 
pain.  Pain  occurs  exclusively  in  organic  diseases  of  the  stom- 
ach (ulcer,  stenosis,  carcinoma,  etc.),  or  some  neighboring 
organ  (gall-bladder,  appendix,  colon,  etc.). 

It  should  always  be  kept  in  mind,  that  unless  patients 
are  very  careful  on  this  point  they  usually  say  they  have 
"pain,"  no  matter  what  may  be  the  exact  nature  of  their 
discomfort,  and  it  also  frequently  happens  that  they  are  really 
unable  to  distinguish  between  actual  pain  and  other  sensory 
disturbances. 

I  include  as  painful  all  sensations  of  a  crampy,  colicky, 
cutting,  stabbing,  boring,  or  burning  nature. 

Among  those  that  are  not  painful,  I  would  classify  sensa- 
tions of  pressure,  fulness,  discomfort,  distention,  nausea, 
weight,  heaviness,  or  globus  hystericus. 


ANAMNESIS  AND  SYMPTOMATOLOGY  3 

5.  If  only  pressure  and  discomfort  are 
felt,  are  they  constant  or  do  they  occur 
only    after    meals? 

Constant  pressure  in  the  abdomen,  which  is  independent 
of  the  nature  of  the  food,  is  characteristic  of  a  gastric  neurosis 
or  of  pressure  from  a  distended  intestine,  or  of  encroachment 
upon  the  abdominal  space  from  ascites,  enlargements  of  the 
liver  and  spleen,  etc. 

When  pressure  is  located  at  the  epigastrium,  inquiry 
should  be  made  as  to  whether  this  pressure  is  accompanied, 
as  is  usually  the  case,  by  fulness,  distention,  flatulence,  the 
rapid  satiation  of  appetite,  lassitude  after  eating,  heartburn, 
regurgitation,  or  vertigo. 

When  pressure  occurs  after  eating,  it  is  essential  to 
determine  whether  it  is  independent  of  the  quality  of  the  food. 

Pressure  which  occurs  only  after  taking  solid  food  indi- 
cates chronic  gastritis. 

Pressure  which  occurs  after  a  meal  of  either  solid  or 
liquid  foods  is  characteristic  of  a  functional  dyspepsia. 

6.  If  you  have  actual  pain,  what  is  its 
character,  and  when  and  where  does  it 
occur? 

Is  it  of  a  cohcky,  cutting,  boring,  or  burning  nature? 
Where  does  it  begin,  and  does  it  radiate?  Is  it  intermittent, 
or  does  it  persist  with  the  same  intensity  for  hours  or  for 
days?  Does  it  recur  every  few  months?  (Cholelithiasis, 
Gastric  Crises.)  Or  does  it  occur  daily  at  a  definite  time  after 
meals?  (Ulcer.)  Is  the  pain  relieved  by  warm  drinks?  (Hy- 
perchlorhydria.)  Or  is  it  relieved  by  the  escape  of  gases  or 
by  defecation?  (Intestinal  Colic.)  Is  vomiting  induced  by 
the  pain,  and  does  relief  follow  vomiting?  Do  you  artificially 
produce  vomiting  to  experience  alleviation  of  the  pain? 
(Pyloric  Stenosis.) 

7.  Doyouvomit? 

If  so,  at  what  time?  Do  you  vomit  early  in  the  morning, 
or    only    after    meals?        Do    you    vomit    certain    foods, — for 


4  DISEASES  OF  THE  DIGESTIVE  CANAL 

example,  vegetables  or  grapes,— which  3-011  have  eaten  a  few 
days  previously?  (Stenosis  of  the  Pylorus.)  Do  you  vomit 
only  mucus?  (Gastritis.)  Do  j^ou  vomit  only  an  acid  fluid? 
(Hypersecretion.)  Are  all  foods  vomited  immediatch-  after 
eating?  (Reflex.)  Or  do  you  vomit  very  profusely  every 
few  days  and  are  you  thereb}"  relieved?  (Ectasia.)  Does 
vomiting  recur  ever}^  few  weeks  or  months,  and  are  you  then 
for  a  period  comparatively  well?  (Gastric  Crises.)  Is  the 
vomiting  associated  with  attacks  of  migraine;  and  if  so,  do 
you  vomit  until  bile  is  present  in  the  vomitus?  (Reflex.) 
Do  3'ou  vomit  a  short  time  after  eating  rich,  indigestible 
foods,  such  as  cabbage,  cheese,  smoked  meat,  hard  boiled 
eggs,  etc.   (Gastritis.) 

8.  What    is    the    condition    of    3- o  u  r    bowels? 

Are  3^our  bowels  regular  or  irregular?  How  often  do  they 
move?  Are  the  stools  formed,  semi-solid,  or  liquid?  If  the 
stools  are  formed,  have  they  a  large  or  small  calibre?  Are  the 
stools  hard  and  knotted  or  pasty  and  spongy?  Do  3"ou  pass 
mucus?  If  so,  is  the  mucus  free  or  is  it  mixed  with  the  feces, 
or  are  the  latter  enveloped  by  membranous  mucus?  Have 
3'OU  observed  sections  of  tapeworms  in  the  stools?  Have  3^ou 
much  gas,  and  is  it  associated  with  abdominal  pain?  If  the 
pressure  of  gas  is  associated  with  pain,  does  the  escape  of 
gas  give  relief?  (See  details  in  the  section  on  Intestinal 
Diseases.) 

9.  What     are     3^  o  u  r     general    symptoms? 

The  physician  must  ascertain  whether  lassitude,  emacia- 
tion, loss  of  appetite,  excessive  hunger,  abnormal  thirst, 
nervous  irritability,  insomnia,  or  mental  depression  is  present. 

10.  From  what  diseases  have  you  pre- 
viousl3^  suffered,  and  what  is  your  family 
history? 

It  is  very  important  to  ascertain  whether  the  patient 
has    previousl3'    suffered    from    serious    affections    like    apical 


PHYSICAL  EXAMINATION  5 

tuberculosis,  venereal  infections,  inflammatory  rheumatism, 
or  typhoid  fever;  and  whether  he  has  been  jaundiced,  or  has 
masturbated  for  a  long  time;  and  above  all,  whether  he  has 
been  physically  or  mentally  over-worked. 

In  addition  to  obtaining  a  careful  personal  history,  it 
is  always  the  duty  of  the  physician  to  inquire  whether  the 
parents  or  brothers  and  sisters  of  the  patient  have  suffered 
from  tuberculosis,  diabetes,  carcinoma,  gout,  or  other  con- 
stitutional diseases. 

The  exact  and  complete  answers  to  all  these  questions 
are  invaluable  in  arriving  at  the  correct  diagnosis. 

Not  until  the  anamnesis  is  obtained  with  the  most  patient 
care,  as  outlined  above,  and  not  until  the  physician  has  there- 
by formed  a  provisional  diagnosis  of  the  disease,  should  he 
proceed  with  the  physical  examination  of  the  patient. 

The  frequency  with  which  patients  consult  a  physician 
with  regard  to  digestive  disturbances,  when  the  actual  trouble 
is  of  an  entirely  different  nature,  emphasizes  the  importance 
of  using  the  greatest  care  in  the  anamnesis,  so  as  to  avoid 
being  misled  at  the  outset  of  the  examination. 

Physical    Examination 

Inspection. — Since  the  physician  must  make  it  his  duty 
in  chronic  stomach  and  intestinal  diseases  to  make  a  thorough 
examination  of  the  entire  body,  he  should  begin  by  carefully 
noting  the  color  of  the  skin,  the  general  nutrition,  the  facial 
expression,  and  above  all,  ''the  habitus."  All  these  things 
are  of  the  greatest  importance,  because  they  often  determine 
the  differential  diagnosis  between  functional  and  organic 
diseases  of  digestion. 

Since  I  assume  the  methods  of  inspection  to  be  known, 
I  shall  merely  remind  the  examiner  of  the  need  of  noticing 
whether  the  patient  is  anaemic,  pale,  cyanotic,  jaundiced, 
bronze-colored,  or  cachectic;  and  whether  he  appears  to  be 
well-nourished,  moderately,  or  very  badly  nourished. 

I  will  here  go  into  detail  in  the  consideration  of  the 
habitus  only. 


DISEASES  OF  THE  DIGESTIVE  CANAL 


According  to  Stiller,  the  normal  habitus,  or  broad  thorax, 
is  differentiated  from  the  so-called  "habitus  enter  opticus," 
which  is  identical  on  the  whole  with  the  paralytic  or  phthisical 
habitus.  The  chief  characteristics  of  the  habitus  enteropticus 
are  the  following: 

A  long,  small  and  usually  flat  thorax;  a  narrow  costal  angle,  so  that 
the  xiphoid  process  is  the  apex  of  an  Sicu\e  angle.  In  patients  with  a  normal 
habitv^,  this  angle  amounts  to  120  degrees  or  more.  Where  habitus  ente- 
ropticus occurs,  the  angle  amounts  to  perhaps  60  degrees.  The  more  acute 
this  angle,  the  more  marked  is  the  habitus  enteropticus,  which  is  accompanied 
by  a  loosening  of  the  costal  cartilages,  so  that  usually  the  tenth  right  and 
left  ribs  fluctuate ;  and  in  severe  cases,  the  cartilages  of  the  ninth  right  and 
left  ribs  also  fluctuate. 


Fig.  1. 


Fig.  2. 


QUmbilicus 


^Umbilicus 
A,  diagram  of  normal  habitus;  B,  diagram  of  habitus  enteropticus. 

In  habitus  enteropticus,  a  vertical  line  drawn  between  the  ensiform 
process  and  the  umbilicus  would  be  much  longer  than  a  line  drawn  at  right 
angles  to  this  vertical  line  and  extending  to  the  anterior  axillary  line.  In 
normal  habitus,  on  the  other  hand,  this  vertical  line  would  be  shorter  or  of 
about  the  same  length  as  the  line  perpendicular  to  it,  extending  to  the 
anterior  axillary  line. 

Therefore,  in  habitus  enteropticus  the  epigastrium  and  hypochondrium 
have  a  greater  longitudinal  than  transverse  diameter,  while  in  normal 
habitus  the  transverse  diameter  of  these  regions  considerably  exceeds  the 
vertical.  This  explains  why  it  is  that  the  organs  occupying  the  epigastrium 
and  the  hypochondrium  must  assume  a  more  nearly  vertical  position  than 
normally.     (See  Figs.  1  and  2). 

If  relaxation  of  the  abdominal  wall  and  diastasis  of  the 
recti  muscles  occur  in  women  with  habitus  enteropticus  after 
pregnancy,  the  intestine  loses  its  support,  so  that  the  stomach 


PHYSICAL  EXAMINATION  7 

also  sinks  downward  and  forward  with  the  greater  curvature 
below  the  umbilicus,  without  the  stomach  itself  being  dilated. 

Normally,  the  transverse  colon  is  usually  two  or  three 
finger-breadths  below  the  greater  curvature  of  the  stomach.  If 
the  latter  assumes  an  abnormally  low  position,  it  is  natural  that 
the  colon  should  also  occupy  a  correspondingly  lower  position. 

In  women  who  have  borne  children,  the  colon  is  rarely 
found  in  the  normal  position, — namely,  one  or  two  finger- 
breadths  above  the  umbilicus. 

In  habitus  enteropticus  the  right  kidney  is  almost  always 
palpable,  the  left  less  often,  though  the  latter  is  more  fre- 
quently displaced  in  men.  The  right  kidney  is  often  palpable, 
even  in  emaciated  children  with  habitus  enteropticus. 

Only  in  the  rarest  cases  are  the  liver  and  the  spleen 
displaced. 

The  significance  of  habitus  enteropticus  in  diseases  of  the  abdominal 
organs,  especially  of  the  stomach,  is,  that  persons  with  habitv^  enteropticus 
are  predisposed  to  functional  diseases  of  the  stomach  and  intestine;  that  is 
to  say,  a  given  irritation  would  produce  disturbances  in  a  person  with 
habitus  enteropticus  which  would  not  affect  a  person  with  normal  habitus. 

All  causes  that  lead  to  insufficient  nutrition  and  to  a  disappearance  of 
fat  from  the  mesentery  and  abdominal  walls  weaken  the  natural  supports 
of  the  abdominal  organs  and  produce  in  the  enteroptotic  individual  some 
active  disease  which  has,  up  to  that  time,  been  latent.  This  disease,  how- 
over,  is  only  of  a  functional  nature,  that  is,  not  leading  to  a  demonstrable 
anatomical  change. 

With  respect  to  its  import,  Stiller  has  designated  this 
entire  habitus  as  ^'asthenia  universalis  congenita."  This  term 
indicates  that  individuals  with  such  habitus  are  predisposed 
to  all  possible  functional  diseases. 

From  the  above-cited  principles  appears  the  extra- 
ordinary significance  of  habitus  enteropticus  in  affections  of  the 
stomach  and  intestine.  The  examiner,  therefore,  should  never 
neglect  to  make  an  absolutely  correct  diagnosis  of  the  habitus. 

1  need  not  emphasize  that  inspection  should  detect  any 
distention  or  retraction  of  the  abdomen,  tumors,  circum- 
scribed swellings,  hernia,  or  diastases  of  the  recti  muscles, 
should  any  exist. 


8  DISEASES  OF  THE  DIGESTIVE  CANAL 

It  is  especially  important  to  recognize  abnormall}^  in- 
creased peristalsis,  the  so-called  "stiffenings"  of  the  stomach, 
small  intestine  or  colon.  These  are  especially  significant  as 
indicating  stenosis  of  the  pylorus,  or  of  the  colon. 

Visible  peristalsis  of  the  small  intestine,  which  is  not 
pathological,  is  found  in  old  women  in  whom  well-marked 
diastases  of  the  recti  muscles  have  remained  after  pregnancy, 
and  who  have  become  extremely  emaciated.  The  peristaltic 
action  of  the  coils  of  the  small  intestine  is  shown  in  a  relief- 
like  manner  upon  the  thin  abdominal  wall  around  the  umbil- 
icus. It  is  necessary  to  guard  against  considering  this  as 
pathological,  or  as  "nervous  peristaltic  unrest"  of  the  intestine, 
for  the  visible  peristalsis  in  these  cases  is  attributable  merely 
to  extreme  emaciation  of  the  patients. 

In  the  course  of  the  examination,  the  tongue  should  also 
be  observed.  Its  appearance  has  only  an  indirect  relation, 
however,  to  diseases  of  the  digestive  organs ;  for  the  less 
thoroughly  the  patient  chews  his  food,  the  more  thickly  the 
tongue  will  be  coated,  and  mastication  in  turn  depends  largely 
upon  the  appetite. 

Percussion. — In  the  examination  of  the  abdomen,  per- 
cussion is  of  minor  value  as  compared  with  palpation.  There- 
fore, the  physician  who  can  palpate  well  scarcely  needs  per- 
cussion at  all,  and  it  would  better  be  dispensed  with,  for  the 
reason  that  it  is  so  often  a  source  of  error. 

In  the  determination  of  the  borders  of  the  stomach,  the 
examiner  will  need  to  make  use  of  it,  if  he  does  not  succeed 
with  palpation;  for  instance,  in  a  patient  whose  stomach  lies 
so  high  that  it  cannot  be  defined  by  palpation. 

Since  distention  of  the  stomach  with  air  or  carbon  dioxide 
gas,  which  were  formerly  much  used  and  considered  very 
important,  is  dispensable  in  practical  diagnosis,  except  when 
localizing  abdominal  tumors,  it  may  be  mentioned  here  and 
will  be  described  briefly  in  the  following  discussion  of  the 
topography  of  neoplasms  of  the  stomach  and  intestine. 

Palpation. — In  examining  a  patient,  one  should  always 
palpate  the  organs  and  parts  in  the  following  order: 


PHYSICAL  EXAMINATION  9 

1.  The  epigastrium  and  stomach. 

2.  The  caecum  and   appendix,  the   ascending   colon,  the 

transverse    colon,    the    sigmoid    flexure,    and    the 
small  intestine. 

3.  The  liver  and  gall-bladder. 

4.  The  spleen. 

5.  The  kidneys. 

6.  The  abdominal  rings. 

7.  The  rectum. 

8.  The  abdominal  cavity  for  tumors,  ascites,  etc. 
Palpation  is  most  successfully  and  easily  performed  in  the 

four  positions  described  below, — the  examiner  sitting  on  the 
right  side,  or  if  left-handed  on  the  left  side,  of  the  patient: 

1.  In  the  dorsal  position  of  the  patient,  the  epigastrium, 
transverse  colon,  caecum,  sigmoid  flexure,  small  intestine,  liver- 
border,  and  gall-bladder  are  to  be  examined. 

2.  In  the  right-side  position  of  the  patient,  the  spleen, 
the  left  kidney,  the  sigmoid  flexure,  and  tumors  of  the  ascend- 
ing colon  are  to  be  examined. 

3.  In  the  left-side  position  of  the  patient,  the  right  kidney, 
the  liver,  the  ascending  colon,  and  possible  tumors  are  to  be 
examined. 

4.  In  the  knee-elbow  position  of  the  patient,  the  anus 
and  the  rectum  are  to  be  examined. 

Although  I  am  well  aware  that  palpation  must  be  learned 
through  practice,  I  should  like  to  mention  the  following  points 
which  have  best  served  me  in  palpation  of  the  abdomen. 

Above  all,  it  is  essential  to  palpate  systematically, — not 
haphazard,  as  is  so  often  done.  The  accompanying  pictures 
will  illustrate  the  art  of  palpation. 

Stomach  and  Epigastrium. —  The  examiner  should  lay 
both  hands  upon  the  epigastrium,'  absolutely  flat  side  by  side, 
not  using  the  thumbs  (see  Fig.  3),  and  should  ask  the  patient 
to  use  the  diaphragmatic  breathing, — inhaling  and  exhaling 
deeply, — during  the  palpation. 

Patients  who  breathe  thoracically  should  be  shown  how 
to  breathe  abdominally, — the  examiner  laying  his   hand  on 


10 


DISEASES  OF  THE  DIGESTIVE  CANAL 


his  own  abdomen  and  ck'nionstrating  to  the  j)atient  that  during 
the  inspiration  the  hantl  is  raised,  and  during  the  expiration 
it  is  lowered.  It  is  clear  that  only  through  diaphragmatic 
breathing  may  the  patient  effect  the  desired  displacement 
of  the  organs  of  the  abdomen, — namely,  the  stomach,  liver, 
spleen,  kidneys,  and    colon,   or   of    possible   existing  tumors. 


Fir,. 


Palpation  of  the  abdomen. 

While  the  patient  inspires  and  expires  as  deeply  as  possi- 
ble, the  hands  of  the  examiner  should  remain  absolutely 
quiet  on  the  epigastrium;  and  only  at  the  moment  of  the 
beginning  of  the  expiration  should  the  finger-tips  be  pressed 
somewhat  deeply  downward.  In  this  way,  all  the  organs  dur- 
ing their  elevation  must  come  into  contact  with  the  finger-tips 
and  are  in  this  manner  best  palpated,  since  the  finger-tips  have 
a  most  delicate  sense  of  touch.  The  examiner  should  attempt 
to  palpate  even  any  slight  irregularities  which  may  be  present. 


PHYSICAL  EXAMINATION  11 

During  palpation  of  the  epigastrium,  the  physician  should 
keep  in  mind  the  possibility  of  existing  tumors,  irregularities  of 
the  liver,  abnormal  pulsations,  epigastric  hernise,  sensitiveness 
to  pressure,  arteriosclerosis  of  the  aorta,  and  palpability  of 
the  pylorus,  which  occurs  not  infrequently.  Of  course,  the  most 
important  question  is,  whether  a  tumor  is  palpable  or  not. 

Determination  of  the  Borders  of  the  Stomach  by  Palpa- 
tion.— The  patient  hes  flat  on  a  reclining  chair  with  the  upper 
part  of  the  body  shghtly  raised,  and  is  given  from  one  to  two 
glasses  of  water  (200  to  400  c.c.).* 

The  examiner  should  place  on  the  epigastrium  of  the 
patient  the  fingers  of  his  right  hand,  spread  out  claw-shaped 
(see  Fig.  4),  and  should  palpate  without  raising  the  finger- 
tips, by  a  short  pushing  stroke,  centimetre  by  centimetre, 
beginning  from  below  and  passing  upward,  until  he  feels  the 
splash  of  the  water  under  his  fingers. 

He  should  not  assume,  however,  that  the  lower  border 
of  the  stomach  is  as  low  as  where  the  splashing  sounds  are 
heard.  While  this  is  often  the  case,  such  a  premise  sometimes 
leads  to  error. 

The  lower  border  of  the  stomach  reaches  only  as  far  as 
the  palpating  fingers  feel  the  water. 

For  the  purpose  of  accomplishing  the  palpatory  percussion 
introduced  by  Obrastzow,  the  examiner  should  require  the 
patient  to  render  the  diaphragm  tense  by  a  deep  inspiration, 
so  that  the  stomach  is  pushed  downward.  The  examiner  can 
also  assist  this  downward  movement  of  the  stomach  by  a 
strong  pressure  of  his  left  hand  upon  the  epigastrium  of  the 
patient  just  below  the  xiphoid  process.  But  we  must  always 
take  into  consideration  the  fact  that  the  lower  border  of  the 
stomach  lies  perhaps  two  or  three  finger-breadths  lower  dur- 
ing inspiration  than  when  the  lungs  are  passive. 

In  enteroptosis  the  greater  curvature,  i.e.,  the  lower 
border  of  the  stomach,  lies,  as  a  rule,  as  low  as  from  one  to 
two  finger-breadths  above  the  level  of  the  umbilicus;    while 

*  Persons  with  enteroptosis  require  one  glass  of  water,  while  patients  with 
normal  habitus  need  two. 


12 


DISEASES  OF  THE  DIGESTIVE  CANAL 


in  individuals  with  noniicd  Jiabitus,  the  lower  stomach-border 
lies  a  h-and's  breadth  above  the  umbilicus,  so  that  only  a 
small  portion  of  the  stomach  is  in  contact  with  the  anterior 
abdominal  wall  so  as  to  be  palpable. 

When  habitus  enteropticus  occurs  in  women  who  have 
borne  children,  the  greater  curvature  frequently  lies  below 
the  umbilicus  as  much  as  four  finger-breadths,  without  there 
being  in  any  sense  actual  dilatation  of  the  stomach. 


Fig.  4. 


Obrastzow's  palpatory  percussion  method  for  determining  the  borders  of  tlie  stomach. 

On  the  oase-card  of  the  patient,  the  physician  should  enter  the  findings 
in  the  following  manner: 

For  instance,  if  the  greater  curvature  lies  two  finger-breadths  above 
the  umbilicus,  he  should  record  G.C.  -§  ;  or  if  the  greater  curvature  lies  three 
finger-breadths  below  the  umbilicus,  he  should  record  G.C.  ^  .  If  the  greater 
curvature  extends  to  the  umbilicus,  he  should  record  G.C.  at  U.  He  may- 
add  to  the  above  whether  the  findings  were  during  inspiration  or  expiration. 
These  formulae  express  briefly  and  clearly  the  position  of  the  stomach. 

When  the  patient  has  a  very  broad  thorax  and  strong  ab- 
dominal wall,  the  examiner  cannot  palpate  the  greater  curva- 
ture, even  after  the  patient  has  taken  a  half  litre  of  water, — in 
which  case  the  position  of  the  stomach  is  considered  normal. 


PHYSICAL  EXAMINATION  13 

Besides  this  method  of  Obrastzow's,  there  are  quite  a 
number  of  other  means  for  determining  the  greater  curvature, 
as  well  as  the  position  and  size  of  the  stomach.  Among  these  I 
will  consider  only  distention  of  the  stomach  with  air  by  means 
of  a  stomach-tube  and  a  Davidson  syringe,  or  by  carbon 
dioxide  gas  produced  by  administering  effervescent  mixtures.* 

Either  of  these  methods,  however,  is  disagreeable  to  both  patient 
and  physician,  and  may  be  dispensed  with.  They  are  to  be  used  only  in 
special  cases;  for  instance,  when  it  is  essential  to  demonstrate  whether  a 
tumor  which  is  felt  in  the  epigastrium  is  situated  in  the  anterior  wall  of  the 
stomach,  or  whether  it  lies  behind  the  stomach.  Tumors  lying  behind 
the  stomach  naturally  become  inaccessible  to  palpation  when  it  is  inflated. 

The  Boas  "sound"  palpation  for  the  determination  of  the  posi- 
tion of  the  greater  curvature  is  dispensable  in  general  practice;  likewise 
the  illumination  of  the  stomach  (gastrodiaphany)  introduced  by  Einhorn. 
All  of  these  methods  are  explained  in  detail  in  well-known  text-books. 

For  practical  work,  the  best  of  the  above-mentioned  methods  is 
that  of  Obrastzow. 

In  patients  with  enteroptosis,  the  examiner  can  often  palpate  the 
normal  pylorus,  which  might  easily  be  mistaken  for  a  tumor  by  the 
inexperienced.  It  generally  lies  at  or  near  the  umbilicus,  and  resembles 
a  tumor  about  the  size  of  a  walnut.  It  will  be  recognized  by  the  follow- 
ing characteristics: 

1.  Its  consistency  continually  changes;  it  is  sometimes  as  hard  as 
a  board,  sometimes  so  soft  that  it  is  inaccessible  to  palpation. 

2.  The  expulsion  of  chyme  from  the  pylorus  can  be  heard,  as  well 
as  felt. 

The  Spleen. — The  patient  should  lie  on  his  right  side  on 
the  examining  table,  with  the  arm  not  thrown  upwards  but 
lying  over  the  chest  slightly  flexed,  so  that  the  abdomen  is 
reHeved  of  tension.  The  physician  should  sit  with  his  right  side 
to  the  patient,  laying  his  right  hand  upon  the  left  costal  arch  and 
placing  the  finger-tips  of  his  left  hand  on  the  costal  cartilage. 

The  patient  should  now  be  required  to  take  a  deep  inspira- 
tion, and  the  examiner  should  press  strongly  downward  and 
inward  only  at  the  moment  of  inspiration.     By  this  procedure 

[  *  The  latter  is  best  performed  by  dissolving  about  one  dram  of  tartaric 
acid  in  a  half  glass  of  water,  which  the  patient  is  requested  to  drink;  this  is 
followed  by  an  equal  amount  of  sodium  bicarbonate  dissolved  in  a  hke  quantity 
of  water.] 


14  DISEASES  OF  THE  DIGESTIVE  CANAL 

the-  spleen  is  pushed  below  the  edge  of  the  ribs  so  that  the 
finger-tips  which  are  pressing  downward  slip  over  the  level 
differences  and  detect  any  enlargement  of  the  spleen.  Several 
repetitions  of  this  mode  of  palpation  will  convince  the  examiner 
of  the  correctness  of  his  findings.  Simultaneously  it  should  be 
determined  whether  the  spleen  is  moderately  or  greatly  enlarged, 
whether  it  is  soft  or  hard,  and  whether  the  edge  is  sharp  or  dull. 

The  fact  that  an  enlarged  spleen  occasionally  reaches  even 
as  far  as  the  caecum  need  only  be  mentioned  here.  Percussion 
of  the  spleen  is  quite  valueless;  and  a  spleen  which  cannot 
be  palpated  must,  in  general,  be  considered  as  normal  in  size. 

The  Liver. — The  liver  should  be  first  palpated  in  the  right 
mammar}^  line.  If  it  extends  below  the  edge  of  the  ribs,  the 
examiner  should  palpate  again  with  the  hand  applied  absolutely 
flat  upon  the  abdomen,  and  should  exert  pressure  as  soon  as 
expiration  begins.  Then  the  finger-tips  should  slide  over  the 
liver-border  into  the  soft  tissues  of  the  abdomen. 

The  examiner  should  determine  whether  the  liver  is  hard, 
soft,  smooth,  or  knobbed;  whether  it  has  a  sharp  or  a  rounded 
edge;  whether  it  is  sensitive  to  pressure;  whether  the  left 
lobe  is  especially  enlarged;  whether  the  entire  liver  is  con- 
tracted; and  moreover,  whether  the  gall-bladder  is  sensitive 
to  pressure,  and  whether  or  not  it  is  swollen. 

When  the  liver  is  only  slightly  enlarged,  the  examiner 
should  palpate  somewhat  differently.  He  should  place  the 
eight  fingers  of  both  hands  almost  perpendicularly  on  the 
eleventh  costal  cartilage  and  should  press  the  eight  finger- 
tips (naturally  with  short  nails)  as  deeply  as  possible  down- 
ward toward  the  posterior  abdominal  wall  as  far  as  the  patient 
can  bear  it,  and  should  request  the  latter  to  inspire  as  deeply 
as  possible.  If  the  liver  now  projects  below  the  edge  of  the 
ribs,  it  will  strike  against  the  finger-tips  producing  a  fcehng 
of  sudden  resistance  both  to  the  examiner  and  to  the  patient. 

Naturally,  this  palpation  method  is  possible  only  with 
persons  whose  abdominal  walls  are  not  too  rigid.  In  a  great 
number  of  patients,  the  palpation  of  the  liver  is  not  successful, 
and  the  examiner  must  resort  to  percussion. 


PHYSICAL  EXAMINATION 


15 


There  are  only  a  few  pathological  conditions  in  the  liver 
inaccessible  to  palpation  that  need  to  be  considered  in  a  dis- 
cussion of  diseases  of  the  stomach  and  intestine. 

One  word  more  concerning  the  contracted  liver:  The 
consideration  of  this  affection  is  important  in  order  to  avoid 
confounding  it  with  malignant  tumors.  The  contracted  liver 
is  met  with  almost  exclusively  in  women  who  have  never,  or 
at  least  rarely,  worn  corsets,  but  who  have  always  fastened 

Fig.  5. 


Palpation  of  the  right  kidney. 

their  clothes  around  the  body  wi.th  draw-strings.  For  the 
diagnosis  it  is  necessary  to  demonstrate  that  the  supposed 
malignant  tumor  exists  in  connection  with  the  rest  of  the  liver. 
The  Kidney. — It  is  well  known  that  the  right  kidney  in 
quite  a  large  number  of  women  and  girls  is  palpable;  in  men, 
on  the  other  hand,  rarely  so  except  in  individuals  with  habitus 
enteropticus.  The  right  kidney  should  be  palpated  in  the  left- 
side, and  the  left  kidney  in  the  right-side,  position;  and  always 
bimanually,  the  examiner  placing  one  hand  on  the  region  of 
the  kidney  and  the  other  on  the  corresponding  anterior  region. 
(See  Fig.  5.)  ' 


16  DISEASES  OF  THE  DIGESTIVE  CANAL 

After  the  patient  has  taken  a  deep  inspiration,  the  exam- 
iner should  press  in  deeply  with  the  right  hand  at  the  mo- 
ment when  expiration  begins.  If  he  can  palpate  the  entire 
kidney  and  push  it  here  and  there  from  the  umbilicus  to  its 
normal  position,  this  indicates  "displaced"  kidney.  If  the 
entire  kidney  or  only  a  portion  is  felt  during  expiration,  and 
if  it  returns  during  inspiration  to  its  normal  position,  the 
condition  should  be  designated  as  ''movable"  kidney. 

The  left  kidney  is  palpable  in  exactly  the  same  manner. 
Even  experienced  examiners  have  difficulty  in  differentiating 
a  movable  left  kidney  from  a  displaced  spleen,  as  it  is  often 
impossible  to  decide  whether  the  organ  lying  in  this  position 
is  the  spleen  or  the  left  kidney.  In  men,  the  left  kidney  is 
found  loosened  more  frequently  than  the  right. 

Only  when  the  kidney  returns  during  expiration  to  its 
previous  position  is  the  examiner  justified  in  diagnosing  ''mov- 
able" kidney,  and  not  "displaced"  kidney. 

Three  degrees  of  movable  kidney  are  differentiated: 
The  first  degree  is  present  only  when  the  lower  part  of  the  kid- 
ney is  palpable;  the  second  degree,  when  half  of  the  kidney  is 
palpable;  the  third  degree,  when  the  entire  kidney  is  palpable. 

The  Intestine. — Normally,  the  colon,  the  csecum,  the 
appendix,  and  the  sigmoid  flexure  can  be  palpated  only 
under  the  most  favorable  conditions.  The  small  intestine 
is  too  soft  to  be  palpated. 

The  examiner  should  always  begin  with  palpation  of  the 
sigmoid  flexure  by  placing  the  fingers  of  the  right  hand  upon  the 
abdomen  at  right  angles  to  the  direction  of  the  course  of  the  sig- 
moid, and  attempting  to  roll  the  sigmoid  back  and  forth  under 
the  fingers  by  pressing  downward  against  the  iliac  fossa. 

During  this  rolling  movement,  the  examiner  will  deter- 
mine whether  the  sigmoid  is  empty  or  is  moderately  well 
filled;  whether  it  is  hard  or  soft,  contracted  or  relaxed;  whether 
it  is  sensitive  to  pressure;  and  whether  a  tumor  is  present. 
These  differentiations  naturally  require  some  practice. 

The  transverse  colon  is  palpated  in  the  following  manner: 
The   physician  should   place  both  hands   (thumbs  excepted) 


PHYSICAL  EXAMINATION  17 

close  to  each  other  on  the  middle  of  the  abdomen,  the  finger- 
tips extending  somewhat  above  the  umbilicus;  and,  while 
the  patient  inspires  and  expires  deeply  with  diaphragmatic 
respiration,  should  roll  up  and  down  with  the  tips  of  his  fingers 


Typical  pressure  point  in  gastric  ulcer. 

and  at  the  beginning  of  each  expiration  press  downward 
lightly.  (See  Fig.  3.)  In  this  way  he  is  able  to  differentiate, 
unless  the  colon  is  completely  relaxed,  as  to  whether  the 
transverse  colon  is  soft  or  hard,  sensitive  or  insensitive  to 
pressure,  or  whether  it  feels  like  a  cord,  more  or  less  filled. 

As  a  rule,  a  pathologically  altered  transverse  colon  only  can 
be  felt,  except  in  cases  of  habitus  enteropticus,  with  descent  of  the 


18 


DISEASES  OF  THE  DIGESTIVE  CANAL 


intestine  and  relaxation  of  the  abdominal  walls  after  pregnancy. 
In  this  .latter  case,  a  normal  colon  is,  as  a  rule,  palpable. 

In  the  normal  habitus,  the  colon  lies  three  or  four  finger- 
breadths  above  the  umbilicus  ( 'u'^ ).    In  habitus  enteropticus,  the 


Fig. 


Typical  pressure  zone  in  liver  and  gall-bladder  affections. 

transverse  colon  lies  at  the  level  of  the  umbilicus  or  one  finger- 
breadth  above  or  below  it.  In  "hang-belly,"  the  middle  por- 
tion of  the  transverse  colon  may  reach  to  the  symphysis  pubis. 
The  palpation  of  the  colon  is  of  double  importance: 
first,  for  determining  the  position  of  the  intestine  and  of 
possible  existing  tumors;  and  second,  as  a  means  to  assist  in 
the  differential  diagnosis  between  the  two  forms  of  habitual 


PHYSICAL  EXAMINATION 


19 


constipation, — atonic  and  spastic.     Only  in  the  spastic  form 
can  one  feel  the  hard  and  contracted  transverse  colon. 

The  examiner  should  make  it  a  rule  to  lay  the  palpating 
hands  on  the  abdomen  at  right  angles  to  the  course  of  the 


Fig.  8. 


'lii^'.ii^s's 


Pressure  areas  iii  nervous  allecUoiis  of  the  stomach. 

colon.  If  the  transverse  colon  assumes  an  arched  form,  as 
frequently  occurs,  with  the  convexity  downward,  the  right 
half  should  be  palpated  in  a  different  direction  from  the  left 
half.  It  often  happens  that  the  transverse  colon  forms  an 
arch  which  extends  to  the  symphysis,  so  that  the  right  and 
left  sides  of  the  arch  are  almost  vertical.  (U-form  of  the 
transverse  colon.) 


20  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  examination  of  the  remaining  portion  of  the  large 
intestine  should  then  be  made. 

The  palpation  of  the  csecum  is  easily  accomplished  by 
the  following  method: 

The  examiner  should  sit  at  the  right  side  of  the  patient, 
placing  his  left  hand  over  the  ca?cum  at  right  angles  to  its 
course  and  pressing  downward  with  a  rolling  movement. 
Usually  a  gurgling  murmur  is  heard,  which,  by  the  way,  is 
of  only  slight  importance. 

The  examiner  should  attempt  simultaneously  to  palpate 
the  appendix.  With  practice,  this  is  possible  in  a  large  number 
of  cases.  It  lies  generally  in  a  direct  Hne  from  McBurney's 
point  to  the  symphysis.  If  the  attention  is  directed  continually 
to  this  point,  the  examiner  will  find  by  experience  that  the 
normal  appendix  is  easily  felt,  by  the  rolling  pressure  of  the 
finger,  to  be  a  cord  about  the  size  of  a  lead-pencil  and  as  long 
as  the  little  finger.  He  will  also  discover  by  this  method  any 
sensitiveness  to  pressure  or  thickening  of  this  organ. 

The  ascending  and  descending  portions  of  the  colon  are 
less  frequently  accessible  to  palpation.  The}^  are  to  be  pal- 
pated exactly  as  the  other  portions,  bimanually,  by  laying  the 
hand  upon  the  abdomen  always  at  right  angles  to  the  course  of 
the  portion  under  examination,  and  ascertaining  the  condition 
by  a  rolHng  movement  combined  with  downward  pressure. 

It  is  important,  in  making  the  diagnosis,  to  ascertain 
whether  these  organs  are  sensitive  to  pressure ;  whether  they  are 
contracted  or  distended;  or  whether  they  contain  fecal  masses. 

For  the  sake  of  completeness,  it  must  be  ackled  here  that  in  sup- 
posed stomach-diseases,  the  urinary  bladder  can  often  be  palpated;  for 
instance,  in  patients  suffering  with  prostatic  affections.  If  the  examiner 
will  remember  that  unusual  resistance  above  the  symphysis  may  be  caused 
bj''  distention  of  the  urinary  bladder,  no  confusion  should  occur  in  the 
diagnosis.  I  need  scarcely  mention  that  the  examiner  should  always  keep 
in  mind  the  necessity  of  palpating  for  possible  existing  ascites. 

One  other  affection  should  also  be  mentioned  that  is 
often  overlooked  in  practice.  I  refer  to  epigastric  hernia  in 
the  hnea  alba, — ''rupture,"  as  it  is  called  by  the  laity. 


INTERNAL  EXAMINATION  21 

The  abdominal  rings  should  always  be  palpated. 

The  examiner  should  also  look  for  a  sensitiveness  to 
pressure  in  the  abdomen,  and  indeed  in  the  skin,  muscles, 
plexuses,  and  intestines.  Pinching  of  the  skin  is  usually  not 
painful;  in  hysteria,  however,  or  when  there  are  inflammatory 
conditions  of  the  intestinal  organs, — such  as  occur  in  colitis, 
appendicitis,  or  cholelithiasis, — even  a  slight  pinching  of  the 
skin  will  be  quite  painful. 

Head  explains  this  by  assuming  that  there  is  a  projec- 
tion of  pain  to  the  skin  overlying  the  inflamed  organs. 

Finally,  the  examiner  should  test  the  back  of  the  patient 
for  sensitiveness  by  means  of  pressure  and  striking  of  the 
muscular  parts  on  both  sides  of  the  spinal  column. 

According  to  Boas,  in  gastric  ulcer  the  skin  to  the  left 
of  the  tenth,  eleventh,  or  twelfth  dorsal  vertebra  will  be  found 
sensitive  to  pressure.  In  cholelithiasis,  on  the  contrary,  the 
skin  to  the  right  of  the  corresponding  vertebra  is  sensitive 
to  pressure.  In  general  neurasthenia,  the  entire  area  along 
both  sides  of  the  spinal  column  is  sensitive  to  pressure,  espe- 
cially in  the  interscapular  and  sacral  regions. 

Having  done  all  this,  the  examiner  should  not  fail  to  pal- 
pate the  anus  and  rectum.  This  is  best  done  in  the  knee-elbow 
position.     (See  details  in  the  section  on  Intestinal  Diseases.) 

Auscultation. — In  the  examination  of  the  abdominal 
organs,  auscultation  may  be  almost  entirely  dispensed  with, 
so  far  as  practical  purposes  are  concerned. 

Internal  Chemical  and  Microscopical  Examination 
of  the  Stomach 

Introductory  Remarks.  —  The  Boas-Ewald  test- 
breakfast  is  used  almost  exclusively  in  the  examination  of 
the  gastric  juice.  This  consists  of  from  60  to  70  grams  of 
dry  wheat  bread  and  400  c.c.  of  cool  water.  The  test-break- 
fast should  be  eaten  by  the  patient  on  an  empt}^  stomach, 
and  exactly  one  hour  afterwards  should  be  siphoned  from 
the  stomach  by  an  ordinary  soft  stomach-tube.  (See  technic, 
page  42.) 


22  DISEASES  OF  THE  DIGESTIVE  CANAL 

•    Before  filtering  the  contents  of  the  stomach,  the  physician 
should  note : 

a.  The  appearance;    whether  the  meal  has  been  well  or 

poorly  digested. 
h.  The  odor;    whether  normal  or  fetid.     [Sour  or  rancid.] 

c.  Whether    blood,   pus,   or   stagnant    remnants    of    food 

are  mixed  with  the  test-breakfast. 

d.  Whether    free    hydrochloric    acid    is    present;    this    is 

done  by  moistening  a  strip  of  congo  paper  with  the 
stomach-contents. 

In  the  well-digested  test-breakfast,  there  should  be  a 
layer  of  finely-divided  bread  on  the  bottom  of  the  glass  con- 
taining the  stomach-contents,  and  over  this  should  be  a  layer 
of  semi-transparent  gastric  juice. 

If  the  test-meal  is  poorly  digested,  as  occurs  in  achylia 
gastrica,  the  stomach-contents  will  consist  of  only  a  small 
quantity  of  fluid  and  many  coarse  lumps  of  bread. 

With  a  little  practice,  the  examiner  will  easily  recognize 
the  macroscopical  differences  between  the  normal  and  the 
impaired  digestion.  He  will  also  observe  that  in  cases  -which 
have  a  normal  acidity  or  a  hyperacidity,  the  stomach-con- 
tents are  easily  removed;  and  that  when  anacidity  exists, 
considerable  effort  and  retching  on  the  part  of  the  patient 
are  required  to  obtain  the  necessary  quantity  of  gastric  juice 
for  examination.  The  examiner  must  sometimes  utilize  even 
the  small  quantity  of  stomach-contents  which  has  remained 
in  the  lumen  of  the  stomach-tube.  In  such  cases,  the  stom- 
ach-tube should  be  quickly  withdrawn  and  the  contents 
blown  into  a  glass.  When  necessary,  even  this  small  quantity 
will  suffice  to  determine  whether  hydrochloric  acid  is  present. 

I  have  never  made  use  of  an  aspirator  for  removing  the  test-break- 
fast from  the  stomach,  although  I  recommend  its  use  to  beginners.  It 
consists  of  a  large  rubber  bulb  connected  with  the  stomach-tube  by  a 
short  glass  tube.  By  pressing  the  air  out  of  the  bulb,  a  vacutun  is  pro- 
duced which  readily  aspirates  the  gastric  contents. 

The  test-breakfast  should  be  filtered  through  a  folded 
filter-paper;   but  if  only  a  very  small  quantity  of  the  test-meal 


INTERNAL  EXAMINATION  23 

has  been  obtained,  the  examiner  would   better    use    instead 
the  unfiltered  stomach-contents. 

The  following  determinations  should  be  made  from  the 
filtrate : 

a.  Total  acidity. — T.A. 

b.  Free    and    combined    hydrochloric    acid    (F.HCl    and 

C.HCl). 

c.  Rennin  and  pepsin,  in  cases  in  which  the  reaction  of 

free  hydrochloric  acid  is  negative,  i.e.,  when  congo 
paper  is  not  colored  blue  by  contact  with  the  gas- 
tric juice.    (See  below.) 

Qualitative  Examination. — For  practical  purposes,  congo 
paper  is  used  almost  exclusively.  [Congo  red  in  solution  is 
even  more  sensitive  than  congo  paper.]  Its  red  color  is 
changed  to  blue  by  contact  with  free  hydrochloric  acid.  The 
more  free  hydrochloric  acid  the  gastric  juice  contains,  the  more 
nearly  sky-blue  will  be  the  color.  If  only  a  small  quantity  of 
free  acid  is  present,  a  weak,  blue-black  coloration  will  result. 

If  free  acid  of  any  kind  is  present  in  the  test-breakfast, 
the  change  of  color  is  always  indicative  of  free  hydrochloric 
acid,  and  never  lactic  or  other  acids,  because  the  Boas-Ewald 
test-breakfast  contains  only  free  hydrochloric  acid. 

Lactic  acid  is  found  present  only 
in  test  -dinners  or  in  conditions  in  which 
there  is  food  stasis.  It  is,  therefore,  quite 
superfluous  to  resort  to  the  Uffelmann  test  when  the  ordinary 
Boas-Ewald  test-breakfast  has  been  given.     (See  below.) 

The  examiner  should  determine  whether  the  congo  reac- 
tion is  normal,  weak,  or  strong.  It  should  be  noted  that  the 
mixture  of  mucus  with  the  stomach-contents  often  disturbs, 
or  even  prevents,  the  reaction.  In  these  cases,  hydrochloric 
acid  may  be  found  in  certain  parts  of  the  test-breakfast,  while 
the  reaction  is  negative  in  other  parts. 

After  practice,  the  examiner  will  be  able  to  form  quite 
accurate  conclusions  concerning  the  degree  of  acidity  of  the 
gastric  juice  by  the  intensity  of  the  coloration  of  the  congo 
paper.    Normal  gastric  juice  changes  congo  paper  to  a  sky-blue. 


24 


DISEASES  OF  THE  DIGESTIVE  CANAL 


Fig.  0. 


i — 25  cj 


Lactic  acid  should  be  tested  for  only  in  cases  in  which 
there  is  stagnation  of  the  stomach-contents. 

The  test  is  made  as  follows: 

One  drop  of  liquor  forri  chloridi  is 
added  to  from  8  to  10  c.c.  of  water  in  a 
test-tube.  The  gastric  filtrate  is  then 
added  drop  by  drop.  If  the  resulting  color 
is  a  yellowish-green,  about  the  shade  of 
Esbach's  reagent,  lactic  acid  is  present. 

The  foregoing  is  Kelling's  modification 
of  Uffelmann's  test. 

[Strauss's  test  is  more  accurate  as  a 
qualitative  test  than  Uffelmann's,  as  the 
latter  is  usually  made;  and  since  the  for- 
mer permits  a  rough  estimate  of  the  quan- 
tity of  lactic  acid  present,  it  is  preferable 
to  Uffelmann's  in  clinical  work.  (See 
illustration.) 

A  small  separating  funnel  should  be 
employed,  graduated  to  hold  o  c.c.  and 
25  c.c.  The  funnel  should  be  filled  to  the 
5  c.c.  mark  with  the  filtered  stomach- 
contents  and  then  to  the  25  c.c.  mark 
with  ether.  The  combination  should  be 
thoroughl}^  shaken  for  two  or  three  minutes 
and  then  allowed  to  stand  until  the  ether 
separates  as  a  clear  layer  above  the  milky 
gastric  juice.  The  stopcock  at  the  lower 
M         ~T  ^  (,T^f_\  Qf  -the  funnel  should  then  be  opened 

l/ll  T'"-'  '^-^ -^  ^^^^^  ^^^  stomach-contents  and  the  ether 
'  allowed  to  run  out  until  the  5  c.c.  mark  is 
reached.  This  leaves  5  c.c.  of  the  ethereal 
extract  of  lactic  acid  in  the  funnel,  which 
should  then  be  filled  with  distilled  water  to 
the  25  c.c.  mark.  Two  drops  of  a  10  per 
cent,  solution  of  ferric  chloride  should  be 

added,  and  the  whole  gently  shaken. 


5C.' 


Separating  apparatus 
suitable  for  making  test  for 
lactic  acid.     (Strauss's.) 


INTERNAL  EXAMINATION  25 

If  0.1  per  cent,  of  lactic  acid  is  present  in  the  stomach- 
contents,  an  intense  yellow-green  color  will  appear;  0.05  per 
cent,  will  show  a  slight  green  color;  quantities  smaller  than 
this,  which  are  of  little  clinical  importance,  give  no  reaction.] 

Quantitative  Examination. — In  practical  work,  the  de- 
termination of  the  total  acidity  of  the  gastric  juice  is 
usually  sufficient,  for  the  reason  that  the  same  test-break- 
fast is  always  given,  the  albuminous  contents  of  which  vary 
only  within  narrow  limits. 

The  examiner  should  have  a  normal  sodium  hydrate 
solution  or  a  normal  potassium  hydrate  solution,  which  can 
be  obtained  in  any  pharmacy.  Every  normal  solution  con- 
tains, dissolved  in  one  litre  of  distilled  water,  a  quantity  of  the 
ingredient  equal  to  its  molecular  weight  in  grams.  A  normal 
sodium  hydrate  solution,  for  instance,  contains  40  grams  of 
sodium  hydrate  to  one  litre  of  water  (Na  -F  0  +  H  =  23  + 
16  +  1=40);  a  normal  HCl  solution,  36.5  grams  to  the  litre 
(H  +  CI  =  35.5  +  1  =  36.5).  A  decinormal  solution  contains, 
naturally,  a  tenth  part  of  a  normal  solution.  Therefore,  one 
litre  of  a  decinormal  NaOH  solution  contains  4  grams  of  sodium 
hydrate,  and  one  litre  of  a  decinormal  HCl  contains  3.65  grams 
of  HCl;   it  follows  therefore  that: 

1  c.c.  decinormal  NaOH  contains  4       milligrams =0.004  NaOH. 
1  c.c.  decinormal  HCl       contains  3.65  milligrams  =0.00365  HCl. 

One  c.c.  of  decinormal  HCl  solution  should  exactly 
neutralize  1  c.c.  decinormal  NaOH  solution. 

To  prepare  the  decinormal  solution  in  the  best  manner, 
the  examiner  should  himself  place  10  c.c.  of  a  normal  solution 
in  a  graduated  beaker  and  dilute  with  distilled  water  to  100  c.c. 

The  examiner  should  now  fill  a  50  c.c.  burette  with  a 
decinormal  hydrate  solution  and  titrate  the  filtered  stomach- 
contents  as  follows: 

Five  c.c.  of  filtered  stomach-contents  should  be  placed  in  a  beaker  or 
large  test-tube.  Two  or  three  drops  of  a  one  per  cent,  alcoholic  phenol- 
phthalein  solution  should  be  used  as  an  indicator.  The  decinormal  sodium 
hydrate  solution  is  now  added,  drop  by  drop,  until  the  contents  of  the 
beaker  remain  a  permanent  red  color.    It  should  be  remarked  here  that  the 


26  DISEASES  OF  THE  DIGESTIVE  CANAL 

reading  of  the  column  of  the  deoinormal  XaOH  sokition  in  the  graduated 
burette  should  always  be  made  from  the  lowest  point  of  the  concavity  of 
the  fluid.  The  examiner  should  avoid  shaking  the  beaker  containing  the 
stomach-contents;  for  if  this  were  done  too  vigorously,  a  portion  of  the  added 
alkali  might  be  neutralized  by  the  carbon  dioxide  of  the  air,  which  would 
be  a  source  of  error  in  the  test. 

Example. — If  for  the  neutralization  of  5  c.c.  of  gastric  juice,  3  c.c.  of 
decinormal  NaOH  solution  were  required,  the  fluid  level  in  the  graduated 
burette  would  be  lowered  from  16.5  to  13.5.  For  the  neutralization  of  100 
c.c.  of  gastric  juice,  twenty  times  as  much  decinormal  solution  w^ould  be 
needed;  therefore,  60  c.c.  of  decinormal  NaOH.  The  total  acidity  (T.  A.) 
has  been  generally  accepted  as  representing  the  amount  of  decinormal 
NaOH  solution  required  to  neutrahze  100  c.c.  of  gastric  juice.  In  our 
example,  therefore,  100  c.c.  of  gastric  juice  contains  as  much  acid  as  60 
c.c.  of  decinormal  NaOH  will  neutralize. 

The  total  acidity  of  the  test-breakfast  is  the  sum  of  the 
following  four  factors: 

1.  Free  hydrochloric  acid. 

2.  Combined  hj^clrochloric  acid. 

3.  Acid  phosphates. 

4.  Traces  of  organic  acids  (COj,  lactic  acid,  acetic  acid, 

butyric  acid,  etc.). 

The  total  acidity  does  not  express,  therefore,  the  per- 
centage of  hydrochloric  acid  in  the  gastric  juice,  but  merely 
the  degree  of  acidity  of  the  latter.  To  determine  in  a  given 
case  the  proportion  of  free  and  of  combined  hydrochloric 
acid,  it  is  necessary  to  deduct  from  the  total  acidity  the  sum 
of  the  acid  phosphates  and  the  organic  acids. 

The  acid  phosphate  and  organic  acid  present  in  the  test- 
breakfast  amount,  on  an  average,  to  from  4  to  8;  but  in  con- 
ditions which  cause  stasis  of  food  in  the  stomach,  to  consider- 
ably more. 

If,  for  example,  the  total  acidity  of  the  gastric  juice  is 
50,  then  the  sum  of  the  free  and  the  combined  hydrochloric 
acid  would  be  50  —  6  =  44;  that  is  to  say,  100  c.c.  of  the 
gastric  juice  in  such  a  case  holds  exactly  as  much  HCl  as  is 
contained  in  44  c.c.  of  decinormal  HCl  solution.  Therefore, 
44  X  0.00365  gram  of  HCl  =  0.01606  gram  HCl,  or  (since 
100  c.c.  =  100  grams)  =  0.1606  per  cent.  =  1.606  per  mille. 


INTERNAL  EXAMINATION  27 

Another  Example. — 

The  total  acidity  of  the  filtrate  =  68 

The  total  phosphates  and  the  organic  acids    =     6 

62HC1 
The  difference  represents  HCl,  which  is  62. 
Therefore,  62  X  0.00365  gram  of  HCl  in  100  c.c.  of  gastric 
juice  =  0.2263  per  cent.  =  2.263  per  mille  HCl. 

By  common  agreement,  the  total  acidity  of  the  test-meal 
is  indicated  in  clinical  records  of  cases  by  the  number  of  cubic 
centimetres  of  decinormal  NaOH  solution  required  to  neutralize 
100  c.c.  of  gastric  juice,  rather  than  in  percentages  of  acidity. 

It  is  proper  to  mention  here  that  values  of  40  to  65  in 
the  Boas-Ewald  test-breakfast  (about  60  grams  of  white  bread 
and  400  c.c.  of  water)  constitute  normal  acidity;  more  than 
65  is  considered  hyperacidity  of  the  gastric  juice;  and  under 
40,  subacidity. 

Although  the  physician  might  approximately  estimate 
the  total  acidity  by  noting  whether  the  congo  reaction  is 
positive  or  negative,  weak  or  strong;  yet  it  is  more  exact  in 
the  qualitative  and  quantitative  examinations  of  the  gastric 
juice  to  determine  accurately  the  different  component  parts 
of  which  the  total  acidity  of  the  gastric  juice  is  composed. 

Topfer's  Method. — By  this  method  the  total  acidity,  the 
free  hydrochloric  acid,  and  the  combined  hydrochloric  acid, 
are  determined  in  the  following  manner: 

1.  The  total  acidity  is  determined,  as  previously  described,  by  using 
phenolphthalein  as  an  indicator. 

2.  Free  HCl  is  estimated  by  the  same  procedure,  using  as  an  indicator 
two  or  tliree  drops  of  a  one-half  per  cent,  alcoholic  solution  of  dimethyl- 
amidoazobenzol,  a  coloring  matter  which,  in  the  presence  of  free  HCl,  appears 
yellow.  The  decinormal  NaOH  solution  is  added  to  the  gastric  juice,  di'op 
by  drop,  until  the  solution  is  permanently  yellow.  Reckoning  on  the  basis 
of  100  c.c.  of  gastric  juice,  the  number  of  c.c.  of  decinormal  NaOH  solution 
used  denotes  as  much  free  HCl  as  is  present  in  the  specimen. 

3.  The  combined  HCl  is  titrated  with  the  use  of  two  or  thi'ee  drops  of 
a  one  per  cent,  aqueous  solution  of  ahzarin  [sodium  alizarin  sulphonate] 
as  an  indicator.  Alizarin  is  a  red-violet  pigment  which  turns  to  j^ellow  all 
acid  factors  of  the  gastric  juice,  with  the  exception  of  combined  HCl,  which 


28  DISEASES  OF  THE  DIGESTIVE  CANAL 

is  immune  to  this  transformation.  The  alizarin  value  represents,  therefore, 
the  sum  of  all  acid  values  of  the  gastrie  juice,  except  that  of  combined  HCl. 
To  ascertain  the  value  of  combined  HCl,  the  examiner  nuist  subtract  the 
alizarin  value  from  the  total  acidity  of  the  specimen. 

Example  of  an   Examination  of  the  Stomach-Contents 
by  Tupfer's  Method 

1.  The  ix^tient,  i\Ir.  Mailer,  was  given  the  Boas-Ewald  test-breakfast, 
consisting  of  from  60  to  70  grams  of  bread  and  400  c.c.  of  water.  After  one 
hour,  this  was  removed  from  the  stomach.  It  was  easily  obtained  and  was 
well  digested.  It  settled  in  two  layers.  The  lower,  in  the  bottom  of  the 
glass,  was  a  fine,  flaky,  crumbly  mass  of  bread.  The  upper  layer  was  a 
somewhat  opaque  fluid,  upon  which  floated  small  ciuantities  of  sputum, 
saUva  and  mucus.  On  pouring  the  gastric  contents  from  one  glass  into 
another,  it  w^as  noted  that  very  little  mucus  was  present,  also  that  it  Avas 
not  tenacious,  the  fluid  contents  leaving  the  glass  drop  by  drop.  The  odor 
of  the  test -breakfast  was  sour,  but  not  offensive.  The  macroscopic  examina- 
tion did  not  reveal  the  presence  of  blood,  pus,  fibres  of  meat,  or  remnants  of 
vegetables.  Congo  paper,  brought  into  contact  with  the  stomach-contents, 
turned  sky-blue. 

Titration  gave  the  following  values: 

1.  Total  acidity  (phenolphthalein  as  an  indicator)  =  60 

2.  Free  HCl  (dimethylamidoazobenzol  as  an  indicator)  =  36 

3.  Combined  HCl  (alizarin  as  an  indicator)  =  20 


4.  Sum  of  free  and  combined  HCl  (36  +  20)  =  56 

5.  The  remaining  acids,  consisting  of  acid  phosphates 

and  organic  acids  (60  —  56)  =    4 

The  examination  gave,  therefore,  the  quantitative  value  of  each  com- 
ponent part  of  the  gastric  juice.  If  the  percentage  of  HCl  is  desired,  the 
HCl  value  should  be  multiplied  by  0.00365;  therefore  56  X  0.00365  ==  0.204 
per  cent.  =  2.04  per  mille  HCl. 

2.  Patient,  Mr.  S.     Diagnosis:  Atrophic  Gastritis. 

One  hour  after  eating  the  Boas-Ewald  test-meal,  the  stomach-con- 
tents were  removed,  but  with  considerable  difficulty,  as  they  were  quite 
thick.  The  upper  layer  of  gastric  juice,  which  normally  is  present,  was 
lacking.  The  specimen  contained  mucus  and  traces  of  fresh  blood.  None 
of  the  food  eaten  by  the  patient  on  the  previous  day  was  found  in  the  stom- 
ach. The  odor  of  the  stomach-contents  was  that  of  bread-pap.  The  test 
with  Congo  paper  was  negative.  The  total  acidity  was  10.  Tcipfer's  method 
was  not  adaptable,  because  there  was  no  free  HCl  present. 


INTERNAL  EXAMINATION  29 

Clinical  Significance  of  HCl. — As  already  mentioned,  the 
normal  total  acidity  of  the  Boas-Ewald  test-breakfast  is  from 
40  to  65.  In  hyperchlorhydria,  the  acidity  amounts  to  from 
65  to  120.     After  the  test-dinner,  the  acidity  is  even  higher. 

Gastric  juice,  the  total  acidity  of  which  is  under  20,  does 
not  react  positively  to  congo  paper,  since,  as  a  rule,  no  free 
hydrochloric  acid  is  present.  The  above  values  are  constant 
because  the  bread  of  the  Boas-Ewald  test-breakfast  contains 
a  nearly  constant  percentage  of  albumen. 

The  absence  of  free  hydrochloric  acid  from  the  gastric 
juice  is  spoken  of  as  ''anacidity."  This  is  not  logical,  since 
combined  hydrochloric  acid  may  still  be  present.  The  total 
acidity  is  never  below  5  or  6,  because  the  Boas-Ewald  test- 
breakfast  always  contains  traces  of  acid  phosphates  and  of 
organic  acids.  The  total  acidity  of  the  gastric  juice,  when  in 
excess  of  8,  indicates  that  the  gastric  mucous  membrane  has 
not  lost  its  secretory  function. 

The  physician  may  nearly  always  assume  that  atrophy  of 
the  gastric  glands  has  occurred  if  the  total  acidity  does  not 
exceed  from  5  to  8.  He  may  also  assume  the  presence  of  an 
interstitial  gastritis  which  has  not  yet  led  to  atrophy  when  the 
total  acidity  amounts  to  from  10  to  15,  and  when  traces  of 
hydrochloric  acid  are  present. 

When  the  total  acidity  exceeds  16,  and  in  those  cases  of 
subacidit}^  in  which  free  hydrochloric  acid  is  secreted  in  quan- 
tities as  high  as  from  20  to  24,  the  existence  of  a  simple  gastric 
catarrh  or  of  a  gastric  neurosis  may  be  indicated,  as  either  of 
these  affections  may  be  associated  with  subacidity  or  anacidity. 

Ferment = Tests. — When  the  stomach -contents  show  an 
absence  of  free  hydrochloric  acid,  and  when  the  total  acidity 
is  20  or  less,  it  is  desirable  to  determine  quantitatively  the 
ferments  of  the  stomach,  since  this  procedure  furnishes  a 
valuable  diagnostic  differentiation  between  neuroses  of  the 
stomach  and  gastritis. 

The  quantitative  test  need  be  made  in  those 
cases  only  in  which  anacidity  exists.  It  is  super- 
fluous and  therefore  absurd  to  examine  the  gastric  juice  for 


30  DISEASES  OF  THE  DIGESTIVE  CANAL 

the  presence  of  ferments  when  the  normal  amount  or  an 
excess  of  hydrochloric  acid  is  secreted,  for  in  these  cases 
the  quantitative  estimation  of  the  ferments  of  the  gastric 
juice  is  of  scientific  value  only. 

As  a  working  rule,  it  may  be  said  that  the  amount  of  the 
gastric  ferments — rennin  and  pepsin — corresponds  with  the 
amount  of  hydrochloric  acid  secreted. 

In  general  work,  an  exact  determination  of  the  total 
acidity  of  the  gastric  juice  will  enable  the  examiner  to  estimate 
with  sufficient  accuracy  the  amount  of  ferments  present, 
provided,  of  course,  he  always  uses  the  same  test-breakfast. 

Rennin-Test. — The  qualitative  examination  of  ren- 
nin has  but  little  diagnostic  value.  On  this  account,  I  always 
use  Boas'  quantitative  test  for  rennin  in  cases  where  there  is 
an  anacid  gastric  juice  This  test  depends  upon  the  dilution- 
principle  and  shows  the  degree  to  which  the  gastric  juice  can 
be  diluted  without  losing  its  property  of  coagulating  milk. 
Boas  neutralizes  the  gastric  juice  before  making  the  test.  I 
consider  this  unnecessary  for  two  reasons:  first,  because  only 
anacid  gastric  juice  is  examined;  and  second,  because  the 
gastric  juice,  being  poor  in  acids,  becomes  so  weakened  by 
dilution  that  its  ability  to  coagulate  milk  is  completely  lost. 
(The  fear  of  this  is  the  reason  some  authors  neutralize  the 
gastric  filtrate.)  I  prefer,  in  performing  the  test,  to  use  test- 
tubes  and  a  water-bath  heated  to  40°  C.  [102°  F.],  rather  than 
beakers  and  an  incubator.  The  details  of  the  rennin-test 
are  as  follows : 

The  examiner  should,  vnth  a  pipette,  introduce  1  c.c.  of  the  gastric 
juice  into  a  graduated  cylinder  of  10  c.c.  capacity.  The  cylinder  should 
then  be  filled  with  tap-water  to  the  10  c.c.  mark.  This  mixture  should 
be  shaken  several  times,  and  half  of  it  should  then  be  poured  from  the 
graduated  cylinder  into  a  test-tube,  which  should  be  marked  "1  to  10" 
with  a  wax  pencil,  and  should  then  be  set  aside.  The  examiner  should  now 
add  water  to  the  5  c.c.  which  remain  in  the  gi-aduated  cyhnder  until  it 
again  reaches  the  10  c.c.  mark  and  should  mix  the  solution  by  inverting  the 
cylinder  several  times,  as  before.  Five  c.c.  of  the  contents  of  the  graduated 
c^'linder  should  again  be  poured  into  a  second  test-tube  marked  "1  to  20." 
The  dilution  of  the   original  1  c.c.  of  the  gastric  juice  should  be  repeated 


INTERNAL  EXAMINATION  31 

several  times  in  like  manner,  and  the  test-tubes  containing  the  respective 
dilutions  should  be  marked  "1  to  40/'  "I  to  80,"  "1  to  160,"  "1  to  320," 
etc.  The  examiner  should  then  add  to  each  test-tube  5  c.c.  of  boiled  [or 
raw]  milk  and  2^  c.c.  of  a  one  per  cent,  calcium  chloride  solution.  After 
the  contents  of  each  test-tube  are  properly  mixed  by  shaking,  the  test- 
tubes  containing  the  specimens  should  be  placed  in  the  water-bath,  which 
has  been  heated  to  40°  C.  [102°  F.].  It  is  usually  best  to  use  a  control  speci- 
men of  only  milk  and  calcium  chloride  solution  in  the  same  proportions  in 
which  they  are  used  in  the  test-tubes  containing  the  specimens.  This  con- 
trol specimen  should  remain  uncoagulated.  Normally,  the  milk  in  the  test- 
tube  which  is  marked  "  1  to  160"  should  show  a  firm,  cake-hke  coagulation; 
and  the  next  specimen,  which  is  marked  "1  to  320,"  should  show  a  fine, 
flaky  coagulation.  All  the  preceding  dilutions  should  show  a  solid,  cake- 
like coagulation.  The  examiner  should  discriminate  between  strong,  or 
cake-like  coagulation,  and  weak,  or  flaky  coagulation.  In  higher  dilutions 
than  the  above,  except  in  cases  of  hypersecretion  of  gastric  juice,  coagulation 
of  the  milk  does  not  occur.  In  hypersecretion,  coagulation  has  been  obtained 
in  a  dilution  of  1  to  800. 

Since  the  examiner  can  easily  prepare  a  water-batli  in 
any  home,  and  since  the  entire  procedure  requires,  at  most, 
fifteen  minutes,  this  test  is  very  suitable  to  general  practice. 

The  clinical  value  of  the  rennin-test  is  as  follows: 

If  the  examiner  finds  normal  rennin-activity  in  a  case  in 
which  the  gastric  juice  is  anacid,  he  may  conclude,  as  a  rule, 
that  the  cause  of  the  anacidity  is  a  gastric  neurosis.  The 
prognosis  is  good  in  such  a  case,  as  it  is  probable  that  the 
secretion  of  hydrochloric  acid  will  return.  If  the  secretion  of 
rennin  is  diminished, — for  instance,  when  coagulation  does 
not  occur  in  a  specimen  which  is  diluted  1  to  100, — -catarrhal 
gastritis  is  generally  present.  Here,  also  the  prognosis  may 
be  favorable,  as  the  secretion  of  hydrochloric  acid  will  again 
be  established  by  rational  treatment.     (See  Special  Section.) 

If,  on  the  other  hand,  the  examiner  finds  an  absence  of 
rennin-activity  in  the  specimens  or  if,  at  best,  a  positive 
reaction  is  obtained  only  when  the  dilution  is  as  low*  as  1  to 
10,  he  should  always  assume  that  total  atroph}^  of  the  glandular 
structures  of  the  stomach  is  present.  If  he  finds  a  positive 
test  only  in  a  dilution  of  1  to  20  or  1  to  40,  a  diagnosis  of 
interstitial  gastritis  may  generally  be  made. 


32  DISEASES  OF  THE  DIGESTIVE  CANAL 

It  should  be  mentioned  here  that  rennin  is  not  always 
secreted  as  an  active  ferment,  but  that  it  is  secreted  from  the 
mucosa  as  an  active  lab-enzyme,  which  is  transformed  into  the 
active  rennin-ferment  by  the  action  of  hydrochloric  acid. 

The  calcium  chloride  solution  exerts  practically  the  same 
influence  upon  the  lab-enzj^ne  as  does  hydrochloric  acid. 
Although  this  transformation  of  the  lab-enzyme  into  rennin 
by  the  action  of  the  calcium  chloride  is  not  positively  proven, 
the  fact  nevertheless  remains  that  the  examiner  can  conven- 
iently measure  the  milk-coagulating  power  of  the  gastric  juice 
by  this  method. 

To  prove  that  the  coagulation  of  the  milk  was  not  caused  by  traces 
of  combined  hydrocliloric  acid,  which  might  still  be  present  in  the  diluted 
specimens,  the  following  test  should  be  made: 

The  examiner  should  prepare  two  test-specimens  of  gastric  juice,  each 
of  which  is  diluted  1  to  100.  One  of  these  is  then  boiled.  The  examiner 
should  then  add  5  c.c.  of  milk  and  2^  c.c.  of  one  per  cent,  calcium  chloride 
solution  to  each  specimen,  after  which  he  should  place  them  in  a  water-bath 
or  incubator,  heated  to  40°  C.  [102°  F.].  The  boiled  specimen  will  remain 
uncoagulated,  because  the  rennin-ferment  is  destroyed  by  boiling;  while 
the  unboiled  specimen  will  be  coagulated  within  a  few  moments. 

In  benign  gastritis,  provided  total  atrophy  of  the  glands 
of  the  mucous  membrane  has  not  yet  occurred,  it  will  be  found 
that  with  improvement  of  the  condition  there  will  be  an  increase 
in  the  production  of  rennin  and  hydrochloric  acid.  In  malig- 
nancy, on  the  other  hand,  it  will  be  found  that  the  production 
of  rennin  will  gradually  sink  to  nil. 

Pepsin-Test. — Although  a  carefull}"  performed  rennin-test 
renders  it  unnecessary  to  make  the  pepsin-test,  the  latter 
should,  nevertheless,  be  described,  for  the  reason  that  in  many 
cases  it  is  the  deciding  factor  as  to  whether  a  malignant  affec- 
tion is  present;  and  after  treatment  for  a  period,  an  increase 
or  a  decrease  in  the  secretion  of  pepsin  has  the  same  signifi- 
cance as  an  increase  or  diminution  of  rennin-activity  in  indicat- 
ing whether  the  anacidity  in  a  suspicious  case  is  caused  by  a 
malignant  disease  or  by  a  simple  inflammatory  affection. 

There  are  several  tests  for  the  c|uantitative  estimation 
of  pepsin,  such  as  the  methods  of  Oppler,  Mette  and  Ham- 


INTERNAL  EXAMINATION  33 

rnerschlag, — the  simplest  and  most  practical,  in  my  opinion, 
being  that  of  Hammerschlag,  which  is  performed  as  follows: 

The  examiner  should  have  on  hand  a  one  per  cent,  solution  of  albumin 
which  contains  about  4  per  mille  of  hydrochloric  acid.  Experience  has 
taught  me  that  this  is  most  easily  prepared  in  the  following  manner: 

To  make  I  litre  of  Hammerschlag's  solution,  I  use: 

1.  30  to  35  c.c.  of  fresh  white  of  eggs. 

2.  4  c.c.  of  concentrated  hydrochloric  acid. 

3.  250  c.c.  of  tap-water. 

This  solution  should  be  renewed  every  two  or  three  weeks,  because 
the  amount  of  albumin  gradually  decreases  through  decomposition.  Ham- 
merschlag uses  dry  egg-albumin,  which,  in  my  opinion,  is  not  so  convenient 
as  the  above. 

The  examiner  should  place  the  30  c.c.  of  egg-albumin  in  an  open  glass 
receiver  and  should  then  add  the  HCl  solution  slowly  while  stirring.  (The 
HCl  solution  is  easily  prepared  by  mixing  4  c.c.  of  the  concentrated  25  per 
cent.  HCl  with  250  c.c.  of  tap-water.)  The  mixture  should  then  be  filtered 
through  a  linen  cloth  properly  arranged  in  a  funnel.  The  entire  procedure 
should  not  require  more  than  5  to  10  minutes.  In  case  the  examiner  does  not 
use  this  test  frequently,  it  is  needless  to  keep  more  than  one-quarter  of  a  litre 
of  Hammerschlag's  solution  on  hand.  The  preparation  of  a  full  litre  of  the 
solution  naturally  requires  four  times  the  indicated  amounts  of  the  ingredi- 
ents; that  is  to  say,  1000  c.c.  of  tap-water,  120  to  140  c.c.  of  egg-albumin 
and  16  c.c.  of  concentrated  hydrochloric  acid. 

The  technic  of  the  pepsin-test  should  be  as  follows: 

Five  c.c.  of  the  gastric  juice  should  be  placed  in  a  test-tube,  which  is 
appropriately  marked  with  a  wax  pencil;  5  c.c.  of  tap-water  should  be 
placed  in  a  second  test-tube  [which  is  marked  "W"];  10  c.c.  of  Hammer- 
schlag's solution  should  then  be  added  to  each  test-tube.  If  necessary,  the 
examiner  may  carry  on  several  albumin-tests  simultaneously.  The  speci- 
mens should  now  be  placed  in  an  ordinary  drinking-glass  containing  water 
at  a  temperature  of  38°  to  40°  C.  [98°  to  102°  F.],  and  then  placed  in  a  water- 
bath  or  an  incubator,  which  should  be  kept  at  a  temperature  of  38°  to 
40°  C.  [98°  to  102°  F.],  by  means  of  a  small  gas  flame,  or  by  the  addition 
of  hot  water. 

The  specimens  should  remain  in  the  incubator  or  water-bath  exactly 
one  hour.  Should  they  be  placed  in  the  incubator  or  water-bath  immediately, 
a  considerable  space  of  time  would  elapse  before  the  specimens  could  reach 
the  temperature  at  which  digestion  occurs.  To  avoid  inaccuracy  in  the 
test,  therefore,  the  examiner  should  place  the  specimens  already  heated,  as 

3 


34  DISEASES  OF  THE  DIGESTIVE  CANAL 

above  directed,  in  the  incubator  or  water-bath.  After  one  hour,  the  speci- 
mens should  be  removed  and  immediatel)'^  placed  in  cold  water  for  two  or 
three  minutes  to  interrupt  pepsin-digestion.  The  examiner  should  now  take 
two  Esbach  tubes,  one  of  which  is  to  be  marked  with  the  name  of  the  patient 
and  the  other  with  the  letter  "W"  (water),  and  should  fill  these  with  the 
respective  specimens  up  to  the  letter  "U."  The  remainder  of  the  specimens 
may  be  thrown  awa3\  The  Esbach  tubes  should  then  be  filled  up  to  the 
mark  "R"  with  Esbach 's  reagent,  then  shaken  well,  closed  with  rubber 
corks,  and  put  aside  to  stand  for  twenty-four  hours.  After  this  time  has 
elapsed,  the  examiner  should  note  the  height  of  the  albumin-column  in 
each  tube. 

Example. — If  the  column  in  the  Esbach  tube  which  contains  the  gas- 
tric juice  stands,  for  instance,  at  1  per  mille,  and  in  the  tube  containing  the 
water,  at  5  per  mille,  there  would  necessarily  be  4  per  mille  of  the  5  per  mille 
of  the  albumin  peptonized,  that  is,  i  digested,  which  equals  SO  per  cent. 

The  examiner  should  enter  in  the  clinical  record  of  the  patient,  there- 
fore, that  the  pepsin-digestion,  according  to  Hammerschlag,  is  80  per  cent. 

Second  Example. — In  a  case  of  hyperchlorhydria,  the  column  of  albumin 
in  the  tube  co^ntaining  the  gastric  juice  was  \  per  mille;  the  tube  containing 
the  w^ater  was  6  per  mille.  Therefore,  5^  per  mille  was  peptonized;  or  out 
of  12  parts,  11  parts  were  digested,  therefore,  \\  digested,  or  91f  per  cent. 

According  to  Hammerschlag,  normal  pepsin-digestion  is 
from  70  to  80  per  cent.;  in  hyperchlorhydria,  90  per  cent.; 
while  in  cases  of  subacidity  or  anacidity,  there  are  values  as 
low  as  10  per  cent.,  or  even  smaller. 

As  a  rule,  the  intensity  of  pepsin-digestion  coiTesponds 
to  the  amounts  of  hydrochloric  acid  and  rennin  secreted  by 
the  gastric  juice.  When  there  is  normal  acidity  or  hyper- 
acidity, the  tube  which  contains  the  gastric  juice  is  usually 
cloudy,  because  the  albumin  of  the  gastric  juice  remains  in 
suspension,  since  it  is  not  affected  by  Esbach's  reagent  and 
is  not  precipitated  as  a  sediment. 

In  general  work,  the  pepsin-test  is  employed  only  in 
cases  of  subacidity  or  anacidity.  From  the  practical  stand- 
point the  rennin-test  suffices,  however,  when  there  is  anacidity 
of  the  test-breakfast;  but  it  is  advisable  to  perform  Ham- 
merschlag's  pepsin-test  to  demonstrate  the  presence  or 
absence  of  the  peptonization  of  food  in  cases  in  which  there 
is  stagnation  of  the  contents  of  the  stomach,  in  order  to  assist 
in  making  a  diagnosis  of  the  nature  of  the  lesion. 


INTERNAL  EXAMINATION 


35 


The  following  table  indicates  the  corresponding  amounts 
of  hydrochloric  acid,  rennin,  and  pepsin,  in  the  various  organic 
diseases  of  the  stomach: 


Atrophy. 

Interstitial 
Gastritis. 

Simple 
Catarrh. 

Subacidity. 

Hyperchlor- 
hydria. 

Total  Acidity 

5-6 

6-12 

14-20 

25-40 

70-100 

1-1  to 
1-10 

1-10  to 
1-40 

1-80  to 
1-160 

1-200 

1-200  to 

1-800 

0-5 

10-25 

30-60 

70-80 

90-98 

Motility  Tests. — Test-dinner :  To  test  the  motility  of  the 
stomach,  the  Riegel  test-meal  is  sufficient.  This  consists  of  a 
plate  of  soup,  150  grams  of  beefsteak,  a  roll  of  bread,  a  small 
dish  of  potato-puree,  some  stewed  fruit  and  one  glass  of  water. 
Seven  hours  after  the  meal,  the  stomach  should  be  washed 
out.  It  will  be  found  empty  if  the  motility  is  normal.  If 
remnants  of  food  are  present,  there  exists  a  weakness  of  the 
muscles  of  the  stomach,  the  so-called  atonia  ventriculi,  and 
sometimes  also  hypersecretion  of  the  gastric  juice. 

Test-supper:  To  test  gross  motor  disturbances  I  use  a 
combination  of  the  methods  of  Boas  and  Strauss.  About 
8  o'clock  in  the  evening,  the  patient  should  eat  a  plate  of  por- 
ridge, cooked  with  rice  or  raisins,  and  one  or  two  slices  of 
bread  and  butter.  The  next  morning  before  breakfast,  or 
about  twelve  hours  after  eating,  the  stomach  of  the  patient 
should  be  lavaged.  A  gross  disturbance  of  the  gastric  motility 
is  present  if  remnants  of  food  are  found,  for  instance,  rice  or 
raisins,  which  are  easily  recognized  macroscopically.  Such 
a  disturbance  is  usually  caused  by  some  mechanical  obstruc- 
tion at  the  outlet  of  the  stomach,  the  nature  of  which  will  be 
considered  later  in  detail.  It  need  scarcely  be  mentioned 
that  the  examiner  will  be  obliged  to  make  use  of  the  micro- 
scope to  recognize  food-remnants  in  the  sediment  of  the  lav- 
age-water,  when  only  minimal  amounts  of  food  are  retained. 

The  Remnant-Test  of  Mathieu-Remond. — This  test  is 
used  to  detect  the  milder  disturbances  of  motility  and  to  ascer- 


36  DISEASES  OF  THE  DIGESTIVE  CANAL 

tain  the  results  of  treatment  in  such  cases.  I  do  not  discharge 
from  ni}'  chnic  any  patient  suffering  from  dilatation  of  the 
stomach  until  the  remnant-test  has  shown  an  approximately 
normal  motility  of  the  stomach. 

The  test  is  made  as  follows: 

Exactly  one  hour  after  the  Boas-Ewald  test-breakfast, 
the  examiner  should  remove  a  portion  of  the  stomach-con- 
tents, "a,"  with  an  ordinary  stomach-tube.  The  portion 
remaining  in  the  stomach  is  the  unknown  quantity  and  is 
designated  "x."  To  determine  ".r,"  the  physician  should 
dilute  the  unknown  quantity,  ''.r, "  with  a  known  quantity 
of  water,  "q,"  which  should  be  introduced  into  the  stomach 
through  the  stomach-tube  and  mixed  thoroughly  with  "x," 
according  to  the  following  equation: 

flj   :  Oj  =  x  +  g   :  X 

i.e.,  the  first  acidity,  " a^"  (before  the  mixture  with  "q," 
therefore,  the  acidity  of  "a,"  since  "a"  and  "x"  have 
the  same  acidity),  is  inversely  proportionate  to  the  second 
acidity,  ''03"  (after  the  mixture  with  "g"),  as  the  respective 
quantities  are  proportionate  to  each  other,  because  the  acidity 
of  " tto"  is  as  much  smaller  than  the  acidity  of  ''a/'  as  the  addi- 
tion   of    water,   "q,"  is    larger.     The    formula,  therefore,  is: 


Example: — 45  c.c.  of  stomach-contents  (a)  are  removed  one  hour  after  the 
test-breakfast,  the  total  acidity  of  which  is  60  (aj.  The  acidity  of  the  portion 
remaining  in  the  stomach  after  mixing  with  400  c.c.  of  water  is  found  to  be  IS 
(a.,).     Therefore, 

"'-  60  —  18         -'^^■ 

In  normal  acidity,  the  total  remnants  of  the  Boas-Ewald 
test-breakfast  amount  to  from  180  to  200  c.c;  in  achylia 
gastrica,  to  about  120  c.c;  in  atony  and  in  hypersecretion, 
to  from  220  to  280  c.c;  and  in  motor  insufficiency  of  the 
stomach,  to  from  300  to  400  and  over. 

Microscopical  Examination  of  the  Stomachi=Contents. — This 
examination,    which    is    very    important    in    diagnosis,    must 


INTERNAL  EXAMINATION  37 

be  made  exclusively  with  fresh  unstained  material  obtained 
from  the  fasting  stomach.  Although  the  examination  of  the 
test-breakfast  reveals  only  starch-granules,  and  now  and  then 
some  yeast-cells,  squamous  epithelium  and  swallowed  sputum, 
all  of  which 'are  of  no  diagnostic  value,  the  examination  of  the 
contents  of  the  fasting  stomach  is  of  the  utmost  importance. 

Fig.   10. 


X,  free  nuclei;    <Sp,  spirals;  -Scft,  mucus;  H,  yeast-cells;    iJ,  epithelium;   A fi,  alveolar  epithelium. 

The  examiner  must  distinguish  between: 

A.  Contents  obtained  from   the  fasting  stomach  with  no  food-rem- 

nants present. 

1.  When  hydrochloric  acid  is  present. 

2.  When  hydrochloric  acid  is  absent. 

B.  Contents  obtained  from  the  fasting  stomach  when  food-remnants 

are  present. 

3.  When  hydrochloric  acid  is  present. 

4.  When  no  hydrochloric,  but  lactic  acid,  is  present. 

1.  The  contents  obtained  from  the  fasting  stomach  which 
contain  hydrochloric  acid,  but  no  food-remnants  (see  Fig.  10) : 

All  of  the  cell-bodies  are  digested  except  the  nuclei  of 
leucocytes  and  epithelia,  which  the  examiner  will  recognize 
as  free,  or  so-called  Jaworski's  nuclei. 

The  mucus  is  streaked. 


38 


DISEASES  OF  THE  DIGESTIVE  CANAL 


The  so-called  myelin,  which  is  converted  into  spirals 
b}'  the  action  of  the  gastric  juice,  is  seen  in  the  sputum  which 
is  almost  always  present  in  the  gastric  contents,  and  easily 
recognized  by  its  light  gray  color. 

M3'elin  spirals,  mucous  threads  and  free  nuclei  are  evi- 
dence, therefore,  of  the  presence  of  hydrochloric  acid  and 
pepsin  in  the  gastric  juice,  since  they  cannot  occur  unless 
these  are  present.  Lactic  acid  cannot  be  responsible  for 
producing  these  changes,  because  it  is  present  only  when 
associated    with    stagnation    of    the    stomach-contents.      The 


Fig.  11. 


E,  epithelium;  L,  leucocytes;  RB,  red  blood-cells;  F,  fat-cells. 

above-mentioned  findings  occur,  therefore,  in  the  gastric 
contents  obtained  from  normal  stomachs,  as  well  as  in  gastric 
neuroses  and  in  hypersecretion. 

2.  Contents  from  the  fasting  stomach  which  contain  no 
hydrochloric  acid  nor  food   (see  Fig.  11): 

In  simple  gastritis  and  in  achylia  gastrica,  the  examiner 
will  often  find  an  alkaline  reaction  of  the  material  removed 
from  the  fasting  stomach.  The  microscopical  examination 
shows  the  presence  of  a  large  number  of  unchanged  cpithelia 
and  at  times,  also,  of  amoebai  and  infusoria. 

In  addition  to  the  above,  if  the  examiner  finds  blood, 
or  a  large  amount  of  pus,  either  in  isolated  clumps  or  mixed 
with  the   epithelial   cells   of   the    gastric    mucosa,   he   should 


INTERNAL  EXAMINATION 


30 


suspect  the  presence  of  a  malignant  process.  Infusoria, 
likewise,  when  found  combined  with  alkaline  stomach-con- 
tents, are  nearly  always  a  sign  of  cancer  of  the  stomach. 

Leucocytes,  as  such,  do  not  indicate  carcinoma.  The  source  of  white 
blood-cells  can  be  determined  only  from  their  association  with  other  cells. 
Leucocytes  originating  in  the  sputum  are  surrounded  by  alveolar  epithelium 
and  myelin  droplets.  Leucocytes  from  the  mouth  are  surrounded  by  squa- 
mous epithelium ;  those  originating  in  the  stomach,by  columnar  epithelium, 

3.  Contents  obtained  from  the  fasting  stomach  which 
contain  food-remnants  and  hydrochloric  acid: 


Fig.  12. 


St,  starch-cells;  //,  yeast-cells;  Sa,  sarcinae;  M,  muscle-fibres;  F,  fat-balls  and  droplets; 
K,  potato-starch  cells. 

Even  macroscopically,  the  different  kinds  of  food, — 
such  as  meats,  fruits,  and  vegetables, — will  be  easily  recog- 
nized. The  microscopic  examination  shows  at  once  whether 
hydrochloric  acid  is  secreted  by  the  following: 

If  either  free  or  combined  hydrochloric  acid  is  present, 
the  well-known  sarcini3e  balls  will  be  seen,  provided  that 
food-stasis  is  not  acute.  Sarcinae  cannot  develop  unless 
stagnation  of  food  has  lasted  two  or  three  days. 

Besides  sarcinae,  the  examiner  will  usually  find  large 
numbers  of  yeast-cells  and  other  fungi  undergoing  sporula- 
tion;  otherwise,  there  are  few  micro-organisms.  Constituents 
of  stagnating  foods,  especially  starch-granules,  meat-fibres, 
fat-droplets,   fat-balls,  fatty-acid  crystals,  remnants  of  vege- 


40 


DISEASES  OF  THE  DIGESTIVE  CANAL 


tables,  all  kinds  of  plant-fibres,  chlorophyll  and  other  plant- 
pigments,  will  be  observed  in  the  microscopic  examination. 
Mucus,  if  present,  is  striped,  as  it  always  is  when  in  an  acid 
medium.     (See  Fig.  12.) 

Stomach-contents  which  contain  both  hydrochloric  acid  and  food  are 
associated  exclusively  with  obstruction  of  the  pylorus,  especially  when  the 
obstruction  has  caused  a  dilatation  of  the  stomach.  The  obstruction  is  al- 
most always  of  a  benign  nature.  Sometimes  it  is  caused  by  a  carcinomatous 
degeneration  of  an  ulcer  of  the  pylorus.  In  these  cases,  the  secretion  of 
hydrochloric  acid  very  often  continues  up  to  the  time  of  the  death  of  the 
patient.  Such  carcinomatous  obstructions  give  the  same  chemical  and 
microscopical  findings  as  benign  stenoses  of  the  pylorus.  They  are  differ- 
entiated clinically  b}^  the  presence  of  a  tumor  and  by  the  malignant  course 
of  the  disease. 

Fig.  13. 
B 


H,  yeast-cells;    .1/,  muscle-fibres;   L.  leucocytes  with  shrunken  nuclei;   B.  Oppler-Boas  bacilli; 
St,  starch-cells;  F,  fat;  E,  epithelium;  K,  potato-starch  cells  with  yeast-cells. 

Stagnation  is  often  so  slight  that  it  can  scarcely  be 
recognized  macroscopically.  Only  the  microscope  shows  the 
presence  of  sarcinse  and  traces  of  food-remnants,  and  there- 
fore a  disturbance  of  the  motility  of  the  stomach,  as  a  con- 
sequence of  the  narrowing  of  the  stomach-outlet.  Very  often, 
besides  sarcinjK,  only  fat  and  starch  are  obtained  from  the 
fasting  stomach,  but  no  muscle-fibres.  The  absence  of  the 
latter  is  explained  by  the  fact  that  the  pepsin  and  hydro- 
chloric acid  of  the  gastric  juice  have  digested  the  meat-fibres 
during  the  night. 


INTERNAL  EXAMINATION  41 

4.  Contents  of  the  fasting  stomach  which  contain  rem- 
nants of  food  and  lactic  acid,  but  no  hydrochloric  acid: 

These  are  microscopically  characterized  by  the  presence 
of  immense  numbers  of  bacilli,  which  will  be  at  once  detected 
by  the  examiner  as  filling  the  spaces  of  the  microscopic 
field  between  the  individual  particles  of  food.  These  are  the 
well-known  Oppler-Boas  lactic-acid  bacilli.  (See  Fig.  13.) 
Sarcinse  do  not  develop  under  conditions  that  favor  the 
formation  of  lactic  acid,  or  very  little  when  a  slight  secretion 
of  hydrochloric  acid  still  remains.  Otherwise,  the  examiner  will 
find  exactly  such  remnants  of  food  as  occur  in  stasis  when 
hydrochloric  acid  is  present.  It  is  unnecessary,  therefore,  to 
repeat  the  details  of  the  microscopical  findings.     (See  Fig.  13.) 

The  Oppler-Boas  bacilli  are  the  microscopical  evidence 
of  lactic  acid  fermentation,  which  occurs  only  under  the 
following  conditions: 

1.  If  there  is  total  atrophy  of  the  gastric  glands. 

2.  If  there  is  stagnation  of  the  ingesta. 

Since  experience  teaches  that  the  latter  occurs  almost  exclusively 
in  carcinoma  of  the  pylorus,  the  presence  of  lactic-acid  bacilli  indicates  to 
the  highest  degree  the  probability  of  a  malignant  stenosis  of  the  pylorus. 

There  is  one  exception  only  when  the  Oppler-Boas  bacilli  occur  in  the 
absence  of  carcinoma,  and  that  is  in  hypertrophic  stenosis  of  the  pylorus, 
the  so-called  cirrhosis  pylori,  which  is  the  result  of  an  atrophic  gastritis  with 
inflammatory  hypertrophy  of  the  pyloric  musculature.  This  is  only  rarely 
observed,  so  that  from  a  practical  standpoint  it  scarcely  ever  comes  under 
consideration,  and  it  is  differentiated  from  carcinoma  of  the  pylorus  only 
through  prolonged  clinical  observation.      (See  Special  Section.) 

Examination  for  Blood. — Aloin-Test:  If  the  microscope 
shows  the  absence  of  red  corpuscles,  the  examiner  should  make 
a  chemical  examination  for  blood  in  the  following  manner: 

Ten  c.c.  of  the  stomach-contents  should  be  placed  in  a  test-tube,  one- 
third  as  much  acetic  acid  added,  i.e.,  3  to  4  c.c,  and  6  to  8  c.c.  of  ether. 
The  mixture  should  be  thoroughly  shaken  and  set  aside  to  allow  the  ether 
to  separate  in  an  upper  layer.  To  the  ether  layer  the  examiner  should  then 
add  30  drops  of  H2O2  and  10  to  15  drops  of  freshly  prepared  alcoholic  solu- 
tion of  aloin  (a  knife-point  of  aloin  added  to  6  to  8  c.c.  of  alcohol).  In  the 
presence  of  haemoglobin,  a  strawberry-red  color  appears  immediately,  or 
within  a  short  time.  Boas  considers  this  test  to  be  of  especial  significance  in 
supposed  cases  of  cancer.      [See  Benzidin-test  for  occiilt  blood,  page  252.] 


42  DISEASES  OF  THE  DIGESTIVE  CANAL 

Final  Remarks. — Besides  the  methods  described  above, 
there  are  quite  a  number  of  delicate  procedures  for  testing 
the  absorption  and  secretion  of  the  stomach  and  intestines, 
and  also  for  ascertaining  the  intensity  of  pain  and  the  sensi- 
tiveness to  pressure  in  the  various  diseases  of  the  digestive 
tract.  Unfortunately,  the  limited  space  of  this  book  does  not 
permit  a  description  of  them. 

Technic,  Indications  and  Contraindications  in  the 
Use  of  the  Stomach=Tube 

The  soft-rubber  stomach-tube  is  used  almost  exclusively 
at  the  present  time, — the  hard-rubber  tube  being  reserved 
for  lavage  of  the  stomach  in  a  comatose  condition,  as  after 
poisoning.  The  soft  tube  should  have,  near  its  lower  extrem- 
ity, one  or  two  lateral  openings,  as  large  as  possible,  but  there 
should  be  no  opening  in  the  end  of  the  tube,  because  of  the 
danger  of  injuring  the  mucous  membrane  of  the  stomach  with 
its  sharp  edges.  The  stomach-tube  should  possess  as  large 
a  lumen  as  possible,  but  its  walls  should  not  be  too  thick. 
For  the  removal  of  the  test-breakfast,  a  large  stomach-tube, 
No.  9  to  No.  11  [American  No.  21-No.  23],  should  be  used 
for  adults;  size  No.  8  [American  No.  16-No.  18],  for  children; 
and  a  Nelaton  catheter  for  babies. 

To  obtain  the  test-breakfast  by  the  "expression-method," 
the  examiner  should  follow  three  procedures: 

1.  The  physician  should  stand  at  the  right  side  of  or  behind  the  patient, 
like  a  dentist  (see  Fig.  16),  and  with  the  left  arm  should  hold  the  patient's 
head  to  prevent  him  from  jerking  it  backwards,  and  should  then  introduce  the 
tube  backward  to  the  epiglottis  with  a  quick  push.  It  is  unnecessary  to 
press  the  patient's  tongue  down  with  a  finger  of  the  other  hand.  This  is 
required  only  if  the  tongue  is  very  thick  and  if  the  pharynx  is  greatly  swollen, 
or  if  the  patient  has  a  very  thick  crista  at  the  posterior  pharyngeal  wall, 
which  narrows  the  oesophageal  opening. 

2.  When  the  point  of  the  sound  has  reached  the  epiglottis,  the  physician 
should  ask  the  patient  to  close  his  mouth  without  bringing  the  teeth  together, 
and,  at  the  same  time,  to  swallow,  which  the  patient  will  be  able  to  do  when 
his  mouth  is  closed.  At  the  moment  of  swallowing,  the  physician  should 
push  the  tube  over  the  closed  epiglottis  into  the  oesophagus  and,  as  quickly 
as  possible,  into  the  stomach,  meanwhile  requiring  the  patient  to  breathe 
deeply  through  the  mouth. 


USE  OF  THE  STOMACH-TUBE 


43 


(A  procedure  which  has  been  recently  suggested  by  Moos,  of  Regcns- 
burg,  is  very  often  found  helpful.  The  patient  should  be  instructed  to  take 
a  mouthful  of  water,  and  after  the  physician  has  introduced  the  stomach- 
tube  into  the  mouth,  he  should  request  the  patient  to  swallow  the  water. 
At  the  same  moment  the  physician  should  push  the  tube,  with  a  slight 
pressure,  over  the  epiglottis  into  the  oesophagus.  Although  the  gastric 
juice  is  slightly  diluted  by  this  procedure,  the  error  is  so  small  that  it  is  of 
scarcely  any  importance.  I  have  succeeded  in  introducing  the  stomach- 
tube  many  times  in  this  wa3^) 

3.  When  the  tube  has  entered  the  stomach,  the  physician  should  tell  the 
patient  to  press  down,  as  when  at  stool.  By  carefully  moving  the  tube  up 
and  down,  vomiting  will  be  induced  from  the  irritating  effect  upon  the  gastric 
mucous  membrane.     During  this  procedure  the  patient  should  lean  forward. 

Fig.  14. 


A,  American  stomach-tube;    B,  Riegel's  stomach-tube. 

In  cases  where  the  gastric  juice  has  a  normal  acidity, 
or  a  hyperacidity,  the  physician  will  very  easily  obtain  the 
necessary  amount  of  stomach-contents  for  examination. 
On  the  other  hand,  this  is  often  very  difficult  in  those  cases 
of  gastritis  in  which  there  is  a  deficiency  of  gastric  secretion. 

Even  if  nothing  is  obtained  from  the  stomach  one  hour  after  the 
test-breakfast  by  this  simple  "expression-method"  of  Boas-Ewald,  it  is  a 
mistake  to  assume  that  the  meal  has  passed  into  the  intestine.  The  exam- 
iner should,  in  such  a  case,  connect  a  glass  funnel  with  the  stomach-tube 
and  wash  out  the  stomach.  He  will  in  this  way  readily  prove  that  often, 
in  cases  of  achylia  gastrica  considerable  amounts,  even  up  to  120  c.c,  of  the 
test-breakfast  ai'e  still  present  in  the  stomach. 


44 


DISEASES  OF  THE  DIGESTIVE  CANAL 


This  method  of  introchieing  the  stomach-tube  has  given  me  the  best 
results,  but  I  admit  that  many  other  methods  have  been  used  with  equal 
success.  Some  examiners,  for  instance,  stand  directly  in  front  of  the  patient 
and  introduce  the  first  finger  of  the  left  hand  into  the  mouth,  for  the  purpose 
of  directing  the  tube  to  the  posterior  pharyngeal  wall.  Others  resort  to  the 
use  of  the  rubber-bulb  aspirator  when  the  stomach-contents  are  not  expelled 
by  the  straining  and  efforts  of  the  patient. 

Finally,  it  must  be  mentioned  that  the  patient  should  never 
bend  his  head  forward  or  backward  on  the  neck  while  the  stom- 
ach-tube is  being  used,  but  should  sit  slightly  forward,  as  in 
eating.  Most  patients  have  the  tendency  to  bend  the  head  back- 
ward at  the  very  sight  of  the  stomach-tube.    In  order  to  prevent 

Fig.   15. 


A,  Modified  Jacques  stomach-tube;    B,  Ewald's  stomach-tube. 


this,  I  generally  hold  the  head  of  the  patient  with  the  entire 
left  arm,  and,  at  the  same  time,  bend  him  shghtly  forward. 

When  hard  bougies  are  being  introduced  into  the  oesoph- 
agus, the  patient  must,  on  the  contrary,  bend  the  head  back- 
wards as  far  as  he  can,  in  order  to  make  the  passage-way 
from  the  incisors  to  the  diseased  portion  of  the  oesophagus 
as  straight  as  possible. 

Indications. — The  stomach-tube  should  be  used  for 
diagnostic  purposes  whenever  it  is  necessary  to  determine, 
in  chronic  cases,  whether  an  organic  or  a  functional  nervous 
affection  exists.    In  cases  where  the  anamnesis  and  the  physical 


USE  OF  THE  STOMACH-TUBE  45 

examination    have    clearly    established    the    diagnosis,    the 
stomach-tube  need  not  be  used. 

For  therapeutic  purposes,  the  stomach-tube  is  rarely  uhmI  at 
the  present  time.  It  is  almost  exclusively  limited  to  lavage  of  the 
stomach  when  stagnation  of  food  has  resulted  from  obstruction 


Method  of  introducing  the  stomach-tube. 


at  the  pylorus.  Now  and  then  the  use  of  the  stomach-tube  is  re- 
sorted to  for  its  psychical  effect  in  neuroses  of  the  stomach,  such 
as  hysterical  vomiting,  nervous  eructation,  nervous  anorexia,  etc. 
Contraindications. — The  stomach-tube  should  never  be 
used  in  cases  of  recent  ulcer,  especially  chlorotic  ulcers,  or 
in  aortic  aneurism,  habitus  apopledicus  [advanced  tuber- 
culosis, heart  affections,  old  age]. 


46  DISEASES  OF  THE  DIGESTIVE  CANAL 

[During  menstruation,  the  tests  for  gastric  secretion 
may  yield'  results  which  vary  considerably  from  those  ob- 
tained at  other  times.] 

Laboratory   Apparatus 

The  equipment  of  a  laboratory  for  diagnostic  and  thera- 
peutic uses  ift  diseases  of  the  stomach  and  intestines,  should 
consist,  if  possible,  of  the  following: 

1.  A  number  of  stomach-tubes  of  different  sizes,  and 
from  70  to  90  cm.  in  length,  of  red  patent-rubber  (Jacques 
Patent),  with  a  blind  extremity  and  two  lateral  openings. 

2.  Two  glass  funnels,  each  having  a  capacity  of  one- 
half  litre,  and  provided  with  a  half-metre  of  rubber  tubing, 
and  also  a  piece  of  glass  tube  to  connect  with  the  stomach- 
or  colon-tube  for  lavage  and  irrigation. 

3.  Some  Naunyn  rectal-tubes,  constructed  just  as  the 
stomach-tubes.  They  should  be  25  cm.  long,  and  the  distal 
end  of  each  should  be  enlarged  like  a  funnel. 

4.  A  number  of  bougies,  and  a  Trousseau's  knob-headed 
sound,  for  use  in  diseases  of  the  oesophagus.  It  is  also  well 
to  have  coin-  and  bone-forceps. 

5.  A  stomach-electrode  (a  stomach-tube,  the  lower  end 
of  which  is  perforated  like  a  sieve  and  which  contains  in  the 
interior  of  the  tube  a  spiral  of  wire,  for  connection  with  one 
pole  of  an  electric  battery). 

6.  An  intestinal  electrode  of  the  same  construction. 

7.  A  faradic  and  a  galvanic  apparatus,  with  two  plate- 
electrodes  about  150  cm.  square,  which  may  be  applied  to 
the  epigastrium  or  the  back  of  the  patient. 

8.  A  burette-stand  with  two  graduated  burettes, — one 
with  a  rubber  faucet  attached  for  decinormal  NaOH  solution, 
the  other  with  a  glass  stop-cock  for  decinormal  HCl  solution. 

9.  A  pipette-stand,  with  different  pipettes  of  1,  5,  and 
10  c.c.  capacity. 

10.  Several  graduates  of  10,  50,  100  and  250  c.c.  capacity. 

11.  One  dozen  glass  beakers  of  about  30  c.c.  capacity, 
for  use  in  titrating  specimens. 


LABORATORY  APPARATUS  47 

12.  A  reagent  stand  and  a  wooden  shelf   for   glassware. 

13.  A  microscope  with  suitable  objectives;  cover-glasses, 
forceps,  and  teasing-needles. 

14.  The  necessary  chemical  reagents,  such  as  solutions 
of  phenolphthalein,  alizarin,  aloin,  congo  paper,  etc.,  besides 
the  chemical  reagents  used  in  the  examination  of  the  urine. 

15.  A  water-bath  or  an  incubator,  and  a  Bunsen  burner. 
IG.  A  Rosenheim  ossophagoscope. 

17.  A  rectoscope  (Herzstein  or  Strauss)  of  two  or  three 
different  lengths. 

18.  A  battery  with  cable  and  a  Casper's  electroscope. 

19.  Einhorn's  gastrodiaphane. 

20.  Bougies  for  use  in  rectal  stenosis. 

21.  Small  glass  funnels,  filter-paper,  and  litmus-paper. 

22.  A  pair  of  scales  and  a  measure  graded  in  centimetres, 
for  use  in  weighing  patients  and  taking  their  measurements. 

23.  A  clinical  case-record. 

24.  A  good  library,  for  which  the  following  works  are 
to  be  recommended: 

Ewald :     ''  Diseases  of  Digestion.  " 

Boas:  "Diagnosis  and  Therapy  of  the  Diseases  of 
Digestion." 

Rosenheim:  "Pathology  and  Therapy  of  the  Diseases 
of  the  Stomach  and  Intestines." 

Riegel:     "Diseases  of  the  Stomach." 

Nothnagel:     "Diseases  of  the  Intestines." 

Schmidt  and  Strassburger :    "Examinations  of  the  Feces. " 

Herz:  "The  Stomach  and  its  Relation  to  Other  Organs 
of  the  Body. " 

Wegele:  "The  Dietetic  Treatment  of  the  Diseases  of  the 
Stomach  and  Intestines." 

[Gautier:     "  Diet  and  Dietetics. " 

Pawlow:     "The  Work  of  the  Digestive  Glands." 

Modern  CHnical  Medicine:  "Diseases  of  the  Digestive 
System. " 

Starling:  "Recent  Advances  in  the  Physiology  of  Diges- 
tion."] 


SPECIAL   SECTION 


Diseases  of  the  (Esophagus 

Of  the  diseases  of  the  oesophagus,  the  following  are  espe- 
cially important  to  the  general  practitioner: 

Acute  and  chronic  catarrh  and  inflammation,  ulcer, 
benign  and  malignant  stenosis,  partial  and  total  dilatation. 

The  individual  diseases  may,  but  need  not,  stand  in 
causal  relation.  For  instance,  catarrh  and  inflammatory 
conditions  may  cause  an  ulcer  of  the  oesophagus;  and  from  an 
ulcer  either  a  carcinoma  may  develop,  or  else  scars  and  con- 
tracture, which  may  give  rise  to  secondary  dilatation  of  the 
oesophagus. 

In  harmony  with  the  plan  and  the  limited  space  of  this 
book,  only  the  most  frequent  and  important  affections  of  the 
oesophagus  will  be  discussed. 

Cancer  of  the  CEsophagus 

General  Remarks. — Cancer  of  the  oesophagus  is  most  fre- 
quent in  elderly  men  who  have  never  previously  suffered  from 
indigestion, — especially  smokers  and  beer-drinkers.  It  occurs 
less  frequently  in  women. 

The  portions  of  the  oesophagus  which  have  a  predilection 
for  cancer  are  those  which  offer  special  resistance  to  food  being 
swallowed : 

a.  The  annular  cartilage. 

h.  The  point  at  the  bifurcation  of  the  trachea. 

c.  The  hiatus  of  the  oesophagus. 

d.  The  cardia. 

The  distance  from  the  incisor  teeth  to  the  cardia  is,  on 
an  average,  40  cm.;  to  the  bifurcation-point,  26  to  27  cm.; 
and  to  the  annular  cartilage,  13  to  14  cm. 

48 


DISEASES  OF  THE  CESOPHAGUS  49 

The  higher  the  carcinoma  is  located  in  the  oesophagus, 
the  more  difficult  is  its  treatment  for  the  physician,  and  the 
more  painful  to  the  patient. 

Carcinomata  seldom  lead  to  complete  clinical  atresia  of 
the  oesophagus,  and  never  to  anatomical  atresia.  In  the  clinical 
course  of  cancer  of  the  oesophagus,  the  passage  of  food  through 
the  oesophagus  will  often  become  easier  through  the  breaking 
down  of  the  obstructive  tumor. 

The  effect  of  an  organic  stenosis  is  frequently  aggravated 
by  spasm  of  the  musculature,  which  results  from  irritation  of 
the  mucous  membrane  above  the  stenosis. 

The  lumen  of  the  oesophagus  may  also  become  completely 
obstructed  by  particles  of  food, — such  as  pieces  of  meat, 
white  bread,  cheese,  etc., — so  that  the  physician  has  appar- 
ently to  deal  with  an  atresia  of  the  oesophagus,  in  which  the 
patient  vomits  everything. 

In  malignant  stenosis  of  the  oesophagus,  the  part  above 
the  stenosis,  first  becomes  hypertrophied,  and  later  on  dilated, 
so  that  stasis  of  the  ingesta  and  lactic  acid  fermentation  occur, 
just  as  in  other  forms  of  stenosis.  Vomiting,  especially  after 
solid  foods,  takes  place  in  every  case;  it  occurs  almost  imme- 
diately after  eating;  while  in  stomach  affections  it  occurs 
much  later.    Cachexia  is  not  always  a  symptom. 

Diagnosis. — The  recognition  of  this  disease  is  relatively 
easy.  The  subjective  symptoms  are  constant  difficulty  in 
swallowing,  usually  loss  of  appetite,  and  vomiting  directly 
after  deglutition.  In  the  first  stage  of  the  disease,  there  is 
difficulty  in  swallowing  soHds  only;  while  later  on,  even  soft 
and  semi-sohd  foods  give  trouble. 

If  such  symptoms  present  themselves  in  elderly  individuals 
who  give  no  history  of  syphilis  or  of  having  swallowed  caustics, 
the  examiner  should  at  once  think  of  the  possible  existence 
of  a  malignant  neoplasm. 

Objective  Symptoms. — The  examiner  should  introduce  a 
soft  tube,  size  No.  10  [American  No.  20  to  No.  23],  to  ascer- 
tain whether  it  will  meet  with  any  obstruction.  If  it  does, 
the  examiner  should  use  a  Trousseau's  bulb-headed  bougie, 

4 


50  DISEASES  OF  THE  DIGESTIVE  CANAL 

which  consists  of  a  whale-bone  handle  with  olive-shaped  ivory 
tips  of  various  sizes.  The  largest  tip  should  be  used  first  to 
determine  accuratel}''  the  distance  of  the  obstruction  from  the 
incisors.  Since  Trousseau's  bougie  is  only  shghtly  flexible,  the 
physician  will  not  so  easily  make  a  mistake  in  measuring  the 
distance  to  the  obstruction,  as  when  using  a  soft-rubber  tube 
which  bends  easily  in  passing  through  the  pharynx  and  oesopha- 
gus. Before  withdrawing  the  bougie,  the  examiner  should  mark 
the  location  of  the  incisors  with  his  finger  and  thumb;  and  this 
distance  should  be  measured,  after  the  bougie  is  removed. 

Fig.   17. 
Ill  I  I 


Trousseau's  cEsophageal  bougie. 

After  the  exact  distance  has  been  accurately  determined, 
an  cesophageal  sound  of  4  to  5  cm.  diameter  should  be  intro- 
duced, and  the  distance  from  the  incisors  to  the  obstruction 
measured.  If,  for  instance,  the  distance  as  measured  by 
Trousseau's  bougie  amounts  to  23  cm.,  and  to  26  cm.  when 
measured  by  the  oesophageal  sound,  the  examiner  can  easily 
estimate  the  width  of  the  strictured  portion  of  the  oesophagus, 
which  information  is  very  important  in  prescribing  the  diet. 

Finally,  the  examiner  should  determine  whether  the 
smallest-sized  olive-tip  passes  through  the  strictured  portion 
into  the  stomach.  If  so,  he  can  determine  the  location  and 
the  extent  of  the  carcinomatous  process  by  introducing  and 
removing  various-sized  bougies. 

Ordinarily  blood,  pus,  and  sometimes  small  portions  of 
cancerous  tissue  will  adhere  to  the  sound  or  bougie,  the 
examination  of  which  makes  the  diagnosis  easier. 


DISEASES  OF  THE  (ESOPHAGUS  51 

The  oesophagoscopic  examination  will  likewise  assist  in 
establishing  the  nature  of  the  lesion.  Its  use,  however,  should 
generally  be  left  to  the  speciahst. 

Other  objective  symptoms  are  sensitiveness  of  the  ster- 
num to  percussion  with  the  finger,  unilateral  vocal-cord  paraly- 
sis, variations  in  the  size  of  the  pupils,  and  other  symptoms 
caused  by  pressure  of  the  cancer  upon  neighboring  structures. 

A  detailed  description  of  the  deglutition-murmurs  will  not  be  given, 
because  they  are  of  only  slight  diagnostic  importance.  It  should  be  remarked, 
however,  that  two  sounds  are  normally  produced  by  the  deglutition-act. 
These  are  best  heard  over  the  cardia,  by  placing  the  stethoscope  in  the  angle 
between  the  xiphoid  process  and  the  left  costal  arch.  The  first  of  these 
sounds  is  a  stenosis-like  murmur  produced  by  contraction  of  the  striated 
musculature  of  the  pharynx,  and  the  second,  a  pressure-murmur  which 
occurs  10  or  15  seconds  later.  The  latter  is  produced  by  contraction  of  the 
non-striated  musculature  of  the  CESophagus.  In  stenosis,  the  latter  murmur 
is  absent,  or  it  occurs  considerably  later  than  normally. 

Differential  Diagnosis. — Cancer  of  the  oesophagus  must 
be  differentiated  from  syphilitic  stenosis,  from  hysterical 
oesophagismus,  and  from  ulcer  with  secondary  contraction, 
as  well  as  from  corrosions  with  cicatricial  formation,  tumors 
of  the  mediastinum,  and  aortic  aneurism.  The  latter  is  of 
especial  importance,  lest  sudden  death  should  result  from 
attempting  to  introduce  the  stomach-tube. 

Complications  of  Carcinoma  of  the  (Esophagus. — The 
formation  of  a  fistula  between  the  oesophagus  and  the  trachea, 
or  between  the  oesophagus  and  the  mediastinum,  is  a  serious 
complication.  The  physician  will  recognize  a  tracheal  fistula 
very  easily  by  severe  attacks  of  coughing  when  liquids  are 
swallowed. 

Treatment. — The  treatment  of  cancer  of  the  oesophagus 
is  divided  into  medicinal,  mechanical,  and  dietetic.  The 
physician  should  advise  operation  only  in  rare  cases,  such 
as  extirpation  of  the  carcinoma  when  it  is  located  in  the 
upper  part  of  the  oesophagus;  and  gastrotomy,  when  it  occu- 
pies the  lower  portion. 

Medicinal  Treatment. — Potassium  or  sodium  iodide  should 
be  given  in  every  case,  because  of  the  possibility  of  syphilis 


52  DISEASES  OF  THE  DIGESTIVE  CANAL 

being  "present.  One  tablcspoonful  of  a  6  :  200  solution  should 
be  given  three  times  a  clay. 

Remedies  which  relieve  spasm  of  the  oesophagus  should 
also  be  given, — such  as  belladonna,  atropine,  eucaine,  cocaine, 
morphine,  or  codeine. 

The  following  prescriptions  have  proved  valuable  to  me: 

1.  I^     Tinctura?  belladonnce  foUorum,  gr.  Ixxx       5.0 

Tincturac  Valerianae,  5  iiss  10.0 

M.  Sig. — Fifteen  to  twenty  drops  t.i.d. 

2.  I^     Codeinse  phosphatis,  gr.  viii-xvi      0.5-1.0 

Aquae  amygdalse  amarae,  giv  15.0 

M.  Sig. — Fifteen  to  twenty  drops  t.i.d. 

3.  ly     Tincturse  belladonnae  foliorum,  gr.  Ixxx-^iiss    5.0-10.0 

Emulsi  amygdalae,  q.s.  ad  3viss  200.0 

M.  Sig. — One  tablespoonful  several  times  daily  before  eating. 

4.  I^     Eucainae  hydrocliloridi,  gr.  v  0.3 

or  Cocainae  hydrocliloridi,  gr.  xv  1.0 

Aquae  destillatae,  oiiss  10.0 

M.  Sig. — To  be  used  by  the  physician. 

The  physician  should  inject  the  eucaine  or  cocaine  solu- 
tion into  the  oesophagus  with  a  long  Nelaton  catheter  and  an 
ordinary  piston  syringe,  the  long  nose  of  which  fits  into  the 
lumen  of  the  catheter.  One  or  two  c.c.  of  the  solution  should 
be  injected  in  this  way,  two  or  three  times  daily.  Belladonna 
or  atropine  tablets  containing  one-half  milligram  [gr.yiTj]  niay 
also  be  used  to  advantage. 

Medicaments  should  be  given  before  meals  when  the 
oesophagus  is  empty. 

Mechanical  Treatment. — This  consists  of  washing  out 
the  oesophagus  and  introducing  oil,  according  to  the  method 
of  Rosenheim,  and  of  dilating  the  cesophagus  with  hard 
conical  bougies. 

To  wash  out  the  oesophagus,  the  physician  should  use  an  ordinary 
soft  stomach-tube.  No.  8  [American  No.  20],  about  90  cm.  long,  the  lower 
end  of  which  contains  two  lateral  openings.  The  tube  should  be  introduced 
to  the  constricted  portion  of  the  a^sophagus,  and  the  stagnating  food  should 
be  washed  out  in  the  following  manner: 


DISEASES  OF  THE  CESOPHAGUS  53 

A  small  glass  funnel,  with  a  capacity  of  from  50  to  75  c.c,  should 
be  connected  with  the  proximal  end  of  the  stomach-tube,  and  warm 
water  should  then  be  poured  into  it  and  the  oesophagus  thoroughly 
cleansed,  by  alternately  raising  and  lowering  the  funnel,  the  greatest  possi- 
ble care  being  taken  to  remove  all  mucus  and  food-remnants.  Following 
lavage,  30  c.c.  of  warm  olive  oil  should  be  introduced.  The  deeper  the 
cancer  is  situated,  the  more  warm  water  and  oil  can  be  used.  When  the 
carcinoma  occupies  the  upper  part  of  the  oesophagus,  the  lavage  and  oil- 
treatment  are  generally  impossible.  One  hour  after  treatment,  the  patient 
may  be  allowed  to  eat. 

In  beginning  treatment,  the  above  procedure  should  be  carried  out 
daily,  preferably  before  breakfast;  and  later  on,  every  few  days.  Patients 
are  considerably  relieved  by  the  lavage  and  oil-treatment  and  are,  as  a  rule, 
after  a  short  time,  able  to  carry  out  the  treatment  alone. 

Indeed,  quite  extraordinary  results  are  obtained  by  the 
lavage  and  oil-treatment  in  this  disease.  Some  patients  who 
had  previously  been  unable  to  swallow,  and  had  vomited 
even  water,  recovered  the  function  of  deglutition  and  were 
able  to  swallow  solids.  (See  Clinical  Cases.)  The  explanation 
of  this  fact,  as  already  mentioned,  is,  first,  that  food-remnants 
had  become  firmly  wedged  in  the  strictured  portion  of  the 
oesophagus,  and,  second,  that  secondary  spasms  of  the  oesoph- 
agus had  occurred.  Both  factors  were  removed  by  lavage 
and  the  oil-treatment. 

Boas'  lavage-sound,  which  has  at  its  lower  end  a    dilatable   rubber 
balloon  for  closing  against  the  cardia,  may  be  used  for  lavage  of  the  oesopha- 
gus.   This  can  be  dispensed  with,  however,  because  the  rounded  end  of  the 
ordinary  stomach-tube  so  effectually  closes  the  strictured  portion  of  the  . 
oesophagus  that  water  does  not  enter  the  stomach  during  the  treatment. 

Dilatation  of  the  obstructed  portion  of  the  oesophagus  and 
the  introduction  of  permanent  cannulse  were  frequently  at- 
tempted in  the  past.     Both  are  now  quite  obsolete. 

The  principle  of  treatment  at  the  present  time,  is  to 
protect  the  diseased  portion  from  mechanical  injury  as  much 
as  possible.  Therefore,  oesophageal  bougies  are  only  rarely 
used  for  therapeutic  purposes. 

Dietetic  Treatment. — The  physician  should  prescribe  such 
foods  as  can  pass  the  obstructed  portion  of  the  oesophagus,  and 


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54  DISEASES  OF  THE  DIGESTIVE  CANAL 

at  the  same  time  will  sustain  the  strength  of  the  patient.    The 
following  so-ealled  "stenosis-fattening"  diet  should  be  given. 

Lavage  and  oil-treatment. 

Tea,  with  125  grams  of  cream. 

250  grams  of  milk. 

A   soup   made   of    flour,    containing    125   grams  of 

cream  and  butter. 
Bouillon  with  1  or  2  tablespoonfuls  of  flour,  and   1 

or  2  yolks  of  eggs  with  butter. 
Tea,  with  125  grams  of  cream. 
Any  kind  of  soup,  made  from  cereals  or  milk. 
Bouillon  with  sago  or  flour  and  butter. 

Besides  the  above,  the  patient  may,  if  he  desires,  be 
given  either  wine,  or  wine  with  eggs,  buttermilk  or  koumiss, 
fruit-juices  diluted  with  mineral  water,  fruit  and  vanilla 
ice-cream,  puro,  sanatogen,  somatose,  etc.  If  the  stenosis  is 
slight,  semi-solids  of  all  kinds,  such  as  the  finest  puree  of 
potato,  spinach,  carrots,  raw  eggs,  etc.,  are  indicated. 

Besides  the  above,  the  physician  should  prescribe  a 
half  wineglassful  of  olive  oil,  one-half  hour  before  the  mid- 
day and  evening  meals,  if  the  patient  does  not  have  a  repug- 
nance toward  it.  For  patients  who  cannot  use  the  oil,  a  cup 
of  the  milk  of  almonds,  the  preparation  of  which  will  be  men- 
tioned later,  may  be  substituted.  Such  a  diet  not  only  main- 
tains the  strength  of  the  patient,  but  may  also  cause  an 
increase  in  weight  if  the  patient  takes  the  proper  physical 
care  of  himself.  I  have  personally  observed,  in  cases  of  this 
kind,  an  increase  of  ten  pounds  or  more. 

If  the  oesophagus  is  very  irritable,  so  that  even  fluids  are 
vomited,  resort  should  be  had  to  the  use  of  nutritive  enem- 
ata  (see  below).  Only  in  those  rare  cases  in  which  the 
symptoms  of  the  disease,  in  spite  of  the  most  careful  treat- 
ment, become  unmanageable,  should  the  patient  be  referred 
to  a  surgeon  for  gastrotomy.     (See  Clinical  Cases.) 


DISEASES  OF  THE  QiSOrilAGUS  55 


CLINICAL    CASES. 

Case  1. — B.  B.,  a  farmer,  aged  50,  for  five  months  had  difficulty  in 
swallowing,  but  no  pain  until  a  few  days  previous.  Hemi-solids  could  be 
swallowed.  Since  then  the  patient  had  vomited  everything,  even  water, 
and  was  extremely  emaciated.  There  was  complete  obstruction  in  the 
oesophagus,  26  cm.  from  the  incisors.  The  presence  of  a  carcinoma,  near 
the  bifurcation,  was  assumed.  In  washing  out  the  oesophagus,  milk  and 
raspberries  were  found  in  the  lavage-water.  Oil  was  introduced,  and  im- 
mediate improvement  of  the  patient  resulted.  Liquids  were  swallowed 
without  difficulty.  Two  days  later,  a  repetition  of  the  lavage  and  oil-treat- 
ment was  made.  Patient  returned  to  his  home  and  was  instructed  to  take 
oil  three  times  a  day,  before  meals.  Seven  weeks  later  there  was  a  gain  of 
one  and  one-half  pounds  in  weight.  The  patient  was  able  to  swallow  zwie- 
back, boiled  pigeon,  etc.  Upon  the  advice  of  a  "quack,"  he  frequently 
used  a  mixture  of  castor  oil  and  linseed  oil  with  compound  licorice  powder. 
Patient  died  later  from  cachexia. 

Case  2. — Mrs.  P.,  a  widow,  aged  76  years,  had  for  several  months  had 
trouble  in  swallowing.  She  was  brought  to  the  polyclinic  because  she 
vomited  everything,  even  water.  Immediately  after  the  first  lavage  and  oil- 
treatment,  the  patient  was  able  to  swallow  semi-solids.  At  first,  treatment 
was  given  daily;  later  on,  only  once  or  twice  a  week.  Three  months  after- 
wards, the  patient  died  without  atresia  of  the  oesophagus  having  developed. 

Case  3. — Herman  L.,  a  farmer,  aged  66  years,  had  for  three  weeks 
found  difficulty  in  swallowing.  Solids  were  vomited.  ■  The  appetite  was 
good.  Weight  154  pounds.  One  and  one-half  years  ago  the  patient  had  been 
kicked  on  the  right  side  of  his  chest  by  a  horse, — which  the  patient  believed 
might  be  the  cause  of  his  present  trouble.  On  examining  the  oesophagus, 
an  obstruction  was  met,  36  to  38  cm.  from  the  incisors,  when  Trousseau's 
bougie  and  the  oesophageal  sound  respectively  were  used.  The  patient 
was  given  the  "stenosis"  diet,  lavage  and  the  oil-treatment.  Atropine, 
belladonna,  or  cocaine  were  occasionally  used.  The  patient  gained  six  pounds 
in  weight  in  one  month.  Two  months  later,  the  patient  weighed  160  pounds. 
Three  months  afterwards,  he  weighed  151  pounds;  and  after  six  months, 
127  pounds.  In  washing  out  the  oesophagus,  blood  and  stagnant  masses 
of  food  were  often  seen  in  the  lavage-water.  Solids  usually  caused  cramp- 
like pains,  which  were  relieved  by  the  use  of  atropine.  Nutrient  enemata 
were  given  from  time  to  time.  The  quantity  of  urine  was  reduced  to  only 
500  CO.  daily.  SaHcylie  acid,  if  swallowed,  gave  a  positive  reaction  in  the 
urine,  showing  that  total  atresia  of  the  oesophagus  had  not  developed.  The 
patient  subsequently  vomited  all  kinds  of  foods,  with  the  exception  of  small 
quantities  of  milk  of  almonds.  The  patient  was  placed  in  a  hospital,  where 
he  died,  six  and  one-half  months  after  the  first  examination  and  seven 
months  after  the  appearance  of  the  earhest  symptom. 


56  DISEASES  OF  THE  DIGESTIVE  CANAL 

Ulcer  of  the  (Esophagus 

Ulceration  of  the  oesophagus  is,  as  a  rule,  rare;  the  most 
freciuent  forms  of  ulcer  are  tubercular,  syphilitic,  catarrhal, 
and  peptic.  Ulcers  are  also  caused  from  caustics,  and  acute 
infectious  diseases,  such  as  diphtheria  and  scarlatina. 

The  oesophagus  is,  naturally,  by  reason  of  its  many  layers  of 
stratified  epithelium,  not  readily  subject  to  infection  and  injury. 

The  symptoms  of  ulceration  of  the  oesophagus  consist 
in  burning,  boring,  and  sometimes  cramp-like  pains  behind 
the  sternum  and  in  the  back,  after  swallowing, — especially 
if  the  ulcer  is  situated  at  the  cardia.  These  symptoms  are 
intensified  by  eating  solids. 

Fissure  and  erosions,  which  occur  especially  at  the  cardia, 
may  produce  the  same  symptoms  as  ulceration  of  the  oesoph- 
agus. 

Ulcers  may  entirely  heal,  or  may  lead  to  sequela3,  the 
most  important  of  which  are  spasm  and  cicatricial  formations, 
with  secondary  dilatation  of  the  oesophagus. 

Treatment. — With  the  exception  of  syphilitic  ulceration, 
— which  of  course  requires  the  use  of  mercury  and  potassium 
iodide, — the  treatment  of  ulceration  of  the  oesophagus  is 
symptomatic.  All  mechanical  irritation  must  be  avoided; 
the  diet,  therefore,  should  be  fluid  or  semi-fluid  in  character. 
Besides  the  narcotics  which  have  been  mentioned  in  discussing 
the  treatment  of  cancer  of  the  oesophagus, — silver  nitrate, 
in  solution  0.5  to  200.0  [grains  viii  to  ounces  vjss],  should  be 
given  in  tablespoonful  doses  three  times  daily,  before  meals. 

In  cases  in  which  spasm  is  a  troublesome  symptom,  it 
is  well  to  employ  belladonna  preparations,  milk  of  almonds, 
warm  olive  oil,  or  the  injection  of  3  c.c.  of  a  3  to  5  per  cent, 
solution  of  cocaine  or  eucaine. 

The  diet,  as  in  cancer,  should  consist  of  milk,  cream, 
butter,  soups,  and  foods  in  puree  form.  In  obstinate  cases, 
and  those  cases  accompanied  with  much  pain,  rectal  nourish- 
ment should  be  resorted  to  for  the  first  week  of  treatment. 

Hot  apphcations  will  be  found  helpful  only  when  the 
ulceration  is  located  at  the  cardia. 


DISEASES  OF  THE  (ESOPHAGUS  57 

Kronig's  method  is  worthy  of  mention,  after  the  acute 
corrosion  of  the  oesophagus  and  stomach  by  poisons.  This 
author  recommends  the  injection  of  150  to  200  c.c.  of  warm 
ohve  oil  into  the  oesophagus  with  a  Nelaton  catheter  and 
piston  syringe,  before  introducing  a  stomach-tube,  to  prevent 
laceration  of  the  affected  area. 

In  phosphorus  poisoning,  this  procedure  is  contraindicated 
for  the  well-known  reason  that  oil  renders  phosphorus  soluble, 
and  thereby  increases  the  danger  of  phosphorus  intoxication. 

Benign  Stenosis 

(Including  Strictures  and  Spasms) 

The  non-malignant  strictures  of  the  oesophagus  are 
caused  either  by  chronic  ulcer,  or  by  cicatrization  after  corro- 
sions with  acids,  alkalies,  and  other  caustics.  Often  several 
strictures  are  found  after  destruction  of  the  oesophageal 
tissue  by  caustics. 

In  patients  with  excessive  irritability  of  the  nervous 
system, — particularly  in  hysteria, — spastic  stenosis  accom- 
panies fissures,  erosions,  or  ulcerations  of  the  oesophagus. 

The  diagnosis  of  cicatricial  stenosis  is  easily  made  from 
the  anamnesis  and  the  examination  of  the  oesophagus.  The 
physician  should  determine  the  degree  of  stenosis  by  the  use 
of  Trousseau's  bougie,  and  should  prescribe  the  diet  of  the 
patient  accordingly. 

Treatment  is  purely  mechanical.  The  physician  should 
pass  a  small-sized  and  later  a  large-sized  bougie  through  the 
strictured  portion  of  the  oesophagus,  into  which  oil  has  pre- 
viously been  introduced.  The  most  suitable  instrument  is 
the  hard,  woven,  conical  English  bougie,  which  is  graded 
from  2  to  14  cm.  in  diameter.  The  lumen  of  the  oesophagus 
in  such  stenosis  is  often  exceedingly  narrow  and  sometimes 
twisted  and  tortuous  in  its  course.  In  such  a  case,  the  exam- 
iner will  be  unable  to  treat  the  condition  in  this  way,  and 
will  be  obliged  to  refer  the  patient  to  a  surgeon.  After  an 
incision  in  the  stomach  has  been  made,  the  oesophagus  can 
be  dilated  from  below  through  an  oesophagoscope. 


58  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  diagnosis  of  spastic  stenosis  is  more  difficult,  and  is 
only  to  be  made  after  observing  the  patient  for  several  weeks. 

The  spastic  contraction  of  the  a?sophagus,  which  occurs 
in  hysterical  individuals,  is  of  considerable  practical  import- 
ance. It  is  questionable  whether  these  stenoses  are  entirely 
of  a  nervous  character,  as  many  think;,  or  whether  some 
organic  lesion, — such  as  an  erosion  or  fissure  of  the  mucous 
surface  of  the  oesophagus, — is  the  cause  of  the  spasm.  Spasm 
of  the  oesophagus  may  be  compared  to  vaginismus,  which  oc- 
curs in  hysterical  women,  with  or  without  lesions  of  the  hymen. 

The  following  features  are  characteristic  of  the  spastic 
stenosis  of  the  oesophagus:  (1)  The  condition  of  the  patient 
is  changeable;  some  days  he  can  swallow  all  kinds  of  solid 
food  without  difficulty,  while  at  other  times  even  fluids  will 
not  pass.  In  fact,  such  patients,  especially  women,  always 
swallow  fluids  more  easily  than  solids.  (2)  In  organic  stenoses, 
only  small-sized  bougies  can  be  introduced  through  the  nar- 
rowest portion;  while  in  spasm  of  the  oesophagus,  even  large- 
sized  sounds  will  enter  the  stomach  if  the  examiner,  after 
introducing  the  bougie  up  to  the  place  of  spasm,  will  wait  a 
moment  until  relaxation  of  the  spasm  occurs.  This  renders 
the  diagnosis  of  spastic  stenosis  certain. 

Treatment. — The  treatment  is  both  general  and  local. 
The  physician  should  prescribe  baths  and  Scotch  douches 
externally,  and  potassium  bromide  and  belladonna  in  a  valerian 
tea  mixture  internally.  Local  treatment  should  consist  of 
introducing  soft  stomach-tubes  of  the  largest  size,  which 
should  be  left  in  position  as  long  as  possible,  up  to  fifteen 
minutes. 

There  are  also,  in  addition  to  the  above  forms  of  stenosis, 
elastic  and  easily  dilatable  cicatrices  of  the  oesophagus,  that 
produce  a  condition  between  cicatricial  and  spastic  stenosis. 
In  this  form,  a  large-sized  bougie  may  be  introduced  without 
much  difficulty. 


DISEASES  OF  THE  CESOPHAGUS  59 


CLINICAL    CASES. 

Case  1. — Clara  L.,  a  dressmaker,  24  5'-ears  of  age,  had  previously  suffered 
from  pleurisy,  chlorosis,  and  chronic  pharyngitis,  which  last  was  treated 
with  applications  of  nitrate  of  silver.  Patient  had  suffered  from  much  worry 
and  excitement.  One  and  one-half  years  ago,  the  patient  began  to  have 
trouble  in  swallowing,  with  a  gradual  exacerbation  of  the  symptom.  She 
was  obliged  to  drink  water  after  eating,  in  order  to  assist  the  passage  of  food 
into  the  stomach.  There  were  often  cramp-like  pains  behind  the  sternum 
after  swallowing.  There  were  marked  emaciation  and  frequent  vomiting. 
The  general  health  of  the  patient  was  changeable.  Repeated  examinations 
of  the  oesophagus  showed  the  following : 

Trousseau's  bulb-headed  bougie  and  a  No.  10  or  No.  11  [No.  20  Ameri- 
can] soft  stomach-tube  was  finally  introduced  into  the  stomach,  after  hav- 
ing encountered  obstructions  at  23  cm.  and  37  cm.,  respectively,  from  the 
incisors.  There  was  a  normal  amount  of  hydrochloric  acid  in  the  gastric 
juice.  The  oesophagus  was  not  dilated.  Before  every  introduction  of  the 
oesophageal  sound,  it  was  necessary  to  cocainize  the  pharynx  and  to  intro- 
duce oil  into  the  oesophagus.  It  was  imjoossible  to  make  an  examination 
with  the  oesophagoscope.  The  introduction  of  the  sound  revealed  the  pres- 
ence of  sensitive  areas  in  the  oesophagus.  Fluids  were  more  easily  swallowed 
at  certain  times  than  at  others.  At  other  times,  all  swallowing  was  impos- 
sible, and  everything  was  vomited.  Upon  one  occasion,  the  patient  ate 
mutton  and  ham-sandwiches  without  any  trouble.  The  weight  of  the 
patient  was  almost  stationary,  with  only  slight  variation. 

Treatment. — Potassium  bromide  and  atropine  were  administered 
internally,  which  gave  considerable  relief.  In  this  case  an  exact  diagnosis 
was  impossible.  We  assumed  the  presence  of  erosions,  which  jDroduced 
spastic  contractions  of  the  oesophagus,  from  irritation  caused  by  the  swallow- 
ing of  the  food.  The  mucous  membrane  of  the  oesophagus  was  hypersensi- 
tive, secondary  to  a  general  hysteria.  The  patient  was  not  cured,  and  the 
after-history  of  the  case  is  not  known. 

Case  2. — Pauline  B.,  46  years  old,  the  wife  of  a  laboring  man,  suffered 
from  strictures  resulting  from  corrosions  of  the  oesophagus.  Five  weeks 
before  entering  the  clinic,  the  patient  accidentally  drank  a  solution  of  caustic 
soda.  Difficulty  in  swallowing  began  immediately.  At  the  beginning  of  the 
treatment,  it  was  impossible  to  pass  a  bougie  through  the  oesophagus. 
Gradually  solid  English  conical-shaped  bougies,  sizes  No.  4  to  No.  11,  could 
be  introduced  into  the  stomach,  as  also  the  sounds  with  olive-shaped  tips. 
By  the  use  of  Trousseau's  bougie,  three  strictured  portions  were  found  in 
the  oesophagus,  from  35  cm.  to  40  cm.  distant  from  the  incisor  teeth.  The 
strictures  were  dilated  daily,  and  the  ability  of  the  patient  to  swallow  rapidly 
increased.  Before  each  treatment,  the  patient  was  given  30  grams  of  olive 
oil  to  facilitate  the  introduction  of  the  bougie  and  sound.     Her  weight 


60  DISEASES  OF  THE  DIGESTIVE  CANAL 

iiioroased  from  13S  to  IGO  pounds.  A  13  mm.  sound  now  entered  the  stomach 
without  any-  trouble.  The  prognosis  was  good.  Secondary  dilatation  of 
the  oesophagus  was  not  liable  to  occur.  The  subcutaneous  injection  of  thio- 
sinamin,  0.2  per  dose,  proved  helpful. 

Case  3. — Frank  M.,  a  servant,  17  years  of  age,  sufforctl  from  cicatricial 
spastic  stenosis  of  the  cardia,  with  secondary  dilatation  of  the  oesophagus. 

The  patient  had  trouble  in  swallowing  for  six  months,  "the  food 
standing  above  the  stomach."  In  order  to  swallow,  the  patient  was  obliged 
to  resort  to  strong  pressure  with  closed  eiDiglottis  after  very  deep  inspira- 
tion. Vomiting  was  frequent.  The  patient  was  very  emaciated  and  ansemic. 
There  was  a  tubercular  catarrh  of  both  apices.  Tubercle  bacilli  were  found 
in  the  sputum.  On  introducing  the  stomach-tube,  an  obstruction  was 
encountered  at  the  cardia,  which,  after  short  hesitation,  gave  way.  There 
was  a  feehng  of  a  flexible  scar  imparted  to  the  hand  holding  the  stomach- 
tube,  at  this  point.  The  oesophagus  was  very  much  dilated,  having  a  capacity 
of  one-quarter  to  one-half  litre.  The  methylene  blue  test  was  positive. 
After  frequent  dilatation  of  the  strictured  portion  and  the  adherence  to  a 
rational  diet,  there  was  an  improvement  in  the  symptoms  and  a  general 
gain  in  weight  from  95  to  106  pounds.  The  gastric  contents  showed  free 
hydrochloric  acid.  The  lung-affection  was  afterwards  cured  b}^  sanatorium 
treatment.  The  patient  was  discharged  and,  after  three  months'  treatment, 
was  able  to  Avork.  At  present  he  introduces  the  bougies  himself  and  is  in  a 
healthy  condition.  The  cause  of  stenosis  of  the  cardia,  in  this  case,  could 
not  be  determined,  but  we  assumed  that  it  was  caused  by  a  tubercular 
ulcer  which  had  healed. 

Dilatation  of   the  (Esophagus   (Diverticulum). 

There  are  two  forms  of  dilatation  of  the  oesophagus: 
(1)  Spindle-shaped,  or  total  dilatation;  (2)  sack-like,  or 
partial  dilatation. 

1.  Spindle-shaped  dilatation  occurs  in  congenital  muscular 
weakness, — the  so-called  idiopathic  dilatation, — although  it  is 
most  probable  that  such  dilatation  is  almost  always  the  result 
of  spastic,  or  cicatricial  stenosis  of  the  cardia,  following  ulcer 
or  erosion.  Frequently  no  organic  stenosis  is  found  at  the 
autopsy  of  such  cases.  One  must  beheve,  therefore,  that 
during  the  life  of  the  patient  a  spastic  stenosis  had  existed, 
which  was  not  demonstrable  at  autopsy. 

Treatment. — The  treatment  of  spindle-shaped  dilatation 
of  the  oesophagus  consists  in  lavage,  dilatation  of  the  con- 
stricted  portion,   and   a   "stenosis-diet."      Recently  the  sub- 


DISEASES  OF  THE  CKSOPHAGUS  61 

cutaneous  injection  of  0.2,  or  a  20  per  cent,  solution,  of  thio- 
sinamin  twice  a  week,  and  continued  about  six  months,  has 
been  suggested. 

I)     Thiosinamin,  5  iiss  10.0 

Glycerini, 

Aquae  destillatse, 

(or  Alcohol  dil.),  iVi  ov     20.0 
M.  Sig. — To  be  used  by  the  physician. 

2.  Sack-shaped  dilatation,  or  diverticulum  of  the  oesopha- 
gus, is  a  lateral  bulging  of  the  walls  of  the  oesophagus,  which 
is  usually  situated  in  its  upper  portion. 

It  is  necessary  to  differentiate  between  pulsion  and 
traction    diverticuli. 

Chronic  Cardiospasm 

[Although  this  condition  might  properly  be  discussed  in 
the  section  on  Diseases  of  the  Stomach,  we  will  consider  the 
matter  here  because  of  its  frequent  association  with  dilatation 
of  the  oesophagus. 

The  cause  of  chronic  cardiospasm  is  still  unknown;  some 
writers  consider  it  a  primary  affection  and  others  as  secondary 
to  an  irritative  lesion  of  the  oesophagus  or  cardia. 

Symptoms. — The  symptoms  of  chronic  cardiospasm  may 
develop  gradually  or  suddenly,  with  difficulty  in  swallow- 
ing. The  dysphagia  may  be  limited  to  a  meal  in  the  begin- 
ning of  the  trouble,  or  it  may  develop  acutely  and  persist  for 
several  months  or  years. 

At  first  solids  and  later  liquids  are  swallowed  with  diffi- 
culty,— particularly  when  taken  either  very  hot  or  very  cold. 
A  short  time  after  eating,  the  patient  experiences  an  impedi- 
ment in  deglutition,  the  food  giving  a  sensation  of  not  having 
entered  the  stomach,  and  he  is  obliged  to  drink  copiously  of 
water  to  assist  the  entrance.  Otherwise,  the  food  will  be 
regurgitated  immediately  or  several  hours  after  eating. 

Depending  upon  the  duration  and  constancy  of  the  cardio- 
spasm, food  is  thus  retained  from  a  few  hours  to  several  days, 
which  causes  a  secondary  dilatation  of  the  oesophagus.  The 
time  at  which  regurgitation  occurs  after  eating  depends  largely 


62  DISEASES  OF  THE  DIGESTIVE  CANAL 

upon  the  amount  of  this  dilatation.  In  the  early  stages,  foods 
are  regurgitated  soon  after  eating;  and  in  the  later  stages. 
when  the  oesophagus  is  widely  dilated,  foods  may  remain  in 
the  oesophagus  48  to  72  hours. 

Normally,  the  oesophagus  has  a  capacit}''  of  from  75  to  80 
e.c.  In  severe  cases  of  cardiospasm  with  secondary  dilatation 
of  the  oesophagus,  this  ma}'  be  increased  to  from  300  to  400  c.c. 

The  amount  of  food  regurgitated  varies  from  a  mouthful 
to  a  half-pint  or  more. 

The  regurgitation  of  liquids  and  foods  through  the  mouth 
and  nose  of  the  patient  during  the  night,  which  occasions  severe 
attacks  of  coughing  and  strangling,  is  a  common  and  character- 
istic symptom,  although  some  patients  are  not  thus  affected. 

Most  patients  suffer  from  hunger;  and  in  cases  of  long 
standing,  there  is  always  marked  emaciation  and  loss  of  weight. 

Aside  from  the  feeling  of  obstruction  to  the  food  entering 
the  stomach,  the  patient  complains  of  subjective  discomfort, 
spasmodic  pain,  burning  and  heaviness  behind  the  lower  third 
of  the  sternum.  Coughing  and  other  reflex  disturbances  are 
frequently  evident. 

Diagnosis  and  Differential  Diagnosis.  —  Cardiospasm  is 
differentiated  from  cicatricial  stenoses  and  compression  ste- 
noses by  mediastinal  tumors,  aortic  aneurisms,  etc.,  by  the 
abihty  in  cardiospasm  to  introduce  a  bougie  or  stomach- 
tube  of  large  size  into  the  stomach.  When  using  the  stom- 
ach-tube, it  is  often  necessary  to  stiffen  the  tube  with  a  wire 
stilette;  and  in  all  cases,  after  introducing  the  end  of  the  tube 
or  bougie  to  the  carclia,  firm  pressure  should  be  exerted  on 
the  bougie,  after  which  the  spasm  of  the  cardia  relaxes 
and  the  stomach-tube  enters  the  stomach,  as  will  be  evidenced 
by  the  presence  of  free  hydrochloric  acid  and  the  gastric 
ferments  of  the  gastric  juice. 

Since  cicatricial  stenosis  is  usually  caused  by  swallow- 
ing caustics,  etc.,  rather  than  by  ulceration  of  the  oesophagus, 
the  early  history  of  the  illness,  and  also  the  physical  examina- 
tion for  aneurism  of  the  aorta,  etc.,  to  exclude  compression- 
stenosis,  are  always  necessary  adjuncts  in  the  examination. 


DISEASES  OF  THE  (ESOPHAGUS  63 

Hysterical  ocsophagismus  is  characterized  by  the  general 
stigmata  of  hysteria  and  the  inconstancy  of  the  oesophageal 
symptoms, — the  patient  suffering  from  spasm  of  the  oesophagus 
for  a  few  meals, — which  is  alternated  with  an  absence  of  all 
local  symptoms  for  several  weeks  or  months. 

In  contradistinction  to  these,  the  symptoms  of  chronic 
cardiospasm  are  more  or  less  constant  and  are  independent 
of  the  nervous  condition  of  the  patient;  and  the  condition 
presents  evidences  of  food-stasis  and  secondary  dilatation  of 
the  oesophagus,  which  are  absent  in  the  former. 

For  the  differential  diagnosis  between  cardiospasm 
with  secondary  dilatation  of  the  oesophagus  and  diverticuli, 
see  below. 

Radiographs  are  at  times  useful,  showing  in  some  cases 
a  cylindrical  dilatation  of  the  oesophagus;  while  in  other 
cases  the  findings  are  negative. 

Treatment. — The  treatment  of  chronic  cardiospasm  is 
mechanical  or  surgical.  Since  successful  results  are  obtained 
by  forcibly  dilating  the  cardia  with  dilatable  rubber  bags, 
the  mechanical  treatment  should  be  attempted  in  every  case 
suffering  from  chronic  cardiospasm. 

This  is  easily  accomplished  by  means  of  a  dilatable  rubber 
bag,  such  as  a  condom,  fastened  over  the  distal  end  of  a  small- 
sized,  stiff-walled  stomach-tube,  or  an  especially  contrived 
rubber  bag  introduced  into  the  cardia  by  means  of  a  wire 
stilette  or  bougie. 

The  rubber  bag  should  be  covered  by  a  silk  bag  to  control 
and  limit  its  amount  of  distention  during  treatment. 

A  mercurial  manometer  is  an  essential  part  of  the  ap- 
paratus, by  which  the  physician  will  be  able  to  control  the 
amount  of  pressure  used  in  distending  the  cardia  within  safe 
limits, — namely,  six  or  seven  pounds. 

The  normal  cardia  cannot  be  safely  stretched  beyond  a 
diameter  of  3.5  cm.  The  silk  bag  which  covers  the  rubber 
balloon  should  therefore  have  a  maximum  diameter,  when 
fully  dilated  at  a  pressure  of  six  or  seven  pounds,  of  about 
3.5   cm.      Early   treatments   should    be   given   with  smaller- 


64 


DISEASES  OF  THE  DIGESTIVE  CANAL 


sized  bags,  these  being  gradually  replaced  with  ones  of  larger 
sizes,  each  one  varying  from  yV  to  J-  of  an  inch  in  size,  at 
each  succeeding  dilatation  of  the  cardia. 

Either  air  or  water  pressure  may  be  used  to  distend  the 
rubber  bag. 

Fig.  18. 


Cardiospasm  dilator  and  mercurial  manometer. 

The  accompanying  illustration  shows  the  complete  ap- 
paratus which  was  devised  by  the  translator  and  successfully 
used  in  a  case  of  chronic  cardiospasm  with  secondary  dilatation 
of  the  oesophagus  of  seven  years'  standing.    (See  Clinical  Case.)] 

Diverticulum. — Any  portion  of  the  oesophageal  wall  that 
possesses  a  congenital  weakness  of  its  musculature  may  become 
bulged  until  a  sack-shaped  diverticulum  is  finally  formed. 


DISEASES  OF  THE  Q^SOrHAGUS  G5 

Traction  diverticuli  arc  formed  from  a  traction-force 
exerted  from  without, —  most  frequently  by  the  retraction 
of  cicatrized  bronchial  glands,  by  which  the  adherent  portion 
of  the  oesophagus  becomes  displaced. 

Symptoms  of  diverticuli  of  the  oesophagus  consist  of 
difficulty  in  swallowing  and  of  frequent  vomiting. 

To  make  a  differential  diagnosis  between  spindle-shaped 
and  sack-like  dilatations  of  the  oesophagus,  the  patient  should 
drink  a  glass  of  water,  colored  with  methylene  blue,  after 
which  the  examiner,  after  introducing  a  stomach-tube,  will 
obtain  at  first  the  blue-colored  contents,  and  later  if  he  intro- 
duces the  tube  still  further  he  will  overcome  the  slight  resist- 
ance, and  the  stomach-tube  will  enter  the  stomach,  when  the 
unstained  gastric  contents  will  be  obtained,  showing  the 
presence  of  hydrochloric   acid. 

The  results  of  the  above  procedure  prove  the  presence  of  a 
spindle-shaped  dilatation;  while  if  the  tube  cannot  be  intro- 
duced past  the  obstruction,  a  diverticulum  should  be  diagnosed. 

Treatment. — The  treatment  of  diverticulum  of  the  oesoph- 
agus is  purely  mechanical,  and  consists  of  lavage  and  dilata- 
tion of  the  oesophagus  with  a  diverticulum-sound,  which  at 
its  point  is  bent  at  an  obtuse  angle,  like  a  prostate-sound. 
This  will  enter  the  stomach  more  easily  than  the  ordinary 
sound;  and  the  physician  should,  at  the  same  time,  avail 
himself  of  the  opportunity  of  introducing  nourishment,  such 
as  milk,  etc.,  to  prevent  the  emaciation  of  the  patient. 

CLINICAL    CASES 
1.   Chronic  Cardiospasm 

[Case  1. — Miss  L.,  age  25.  Mother  and  both  grandmothers  had  suf- 
fered from  stomach  trouble.  Her  mother  died  from  tuberculosis.  The 
patient  had  suffered  from  dyspepsia  all  her  life,  occasionally  experiencing 
severe  burning  pain  in  the  epigastrium.  Several  years  previous  to  her  present 
illness,  she  had  lived  one  year  on  malted  milk  and  cereals,  after  which  she 
had  no  digestive  trouble  until  seven  years  ago  the  patient  suddenly  began 
to  have  difficulty  in  swallowing  solids.  She  was  soon  unable  to  swallow 
either  very  hot,  or  very  cold,  foods  or  liquids.  For  the  past  four  or  five  3'^ears, 
the  patient  had  dysphagia  during  or  after  every  meal.    A  few  minutes  after 

.5 


66  DISEASES  OF  THE  DIGESTIVE  CANAL 

bo<j;inning  to  eat,  she  would  be  obliged  to  drink  several  glassfuls  of  warm 
water  "  to  wash  the  food  down";  otherwise,  what  she  had  eaten  would  be 
regurgitated,  immediately  or  several  hours  later.  Tliere  had  been  occasional 
burning  pain  behind  and  at  the  lower  third  of  the  sternum,  which  was  inde- 
pendent of  eating.  The  patient  had  frequently  been  awakened  at  night  by 
the  regurgitation  of  irritating  foods  and  licjuids  through  the  nose  and  mouth, 
which  caused  severe  attacks  of  coughing  and  strangling.  Patient  had 
gradually  lost  in  v/eight  and  nutrition,  was  extremely  ner^•ous,  and  suffered 
from  insomnia,  ravenous  appetite,  and  constipation. 

Physical  Exomination. — The  patient  was  poorly  nourished  and 
weighed  only  95  pounds.  The  greater  curvature  of  the  stomach  was  2  in. 
below  the  imibilicus.    The  plwsical  examination  was  otherwise  negative. 

Upon  introducing  an  ordinary  soft  stomach-tube,  resistance  was 
encountered  16^  inches  from  the  incisors.  Food  which  had  been  eaten  on 
the  previous  day  was  returned  through  the  tube,  and  had  an  acid  reaction. 
There  was  no  free  hydrochloric  acid  present.  On  one  occasion,  food  eaten 
three  days  previously  was  remo\'ed  from  the  oesophagus,  and  gave  a 
strong  reaction  of  lactic  acid;  the  Boas-Oppler  bacilli  were  present. 

The  capacit}'  of  the  oesophagus  was  350  c.c.  Two  skiagraphs  were 
taken,  which  failed  to  be  of  any  material  assistance  in  the  diagnosis. 

After  repeated  attempts,  the  cardiospasm  relaxed  and  the  stomach- 
tube  entered  the  stomach,  the  contents  of  which  had  a  normal  amount  of 
free  hydrochloric  acid. 

Treatment. — The  cardia  was  stretched  with  a  rubber  bag  dilator  (see 
illustration  and  description  of  apparatus  above),  after  which  the  patient  had 
no  trouble  in  swallowing  for  one  week,  when  the  treatment  was  repeated. 

After  six  or  seven  treatments,  the  cardiospasm  disappeared,  food 
entered  the  stomach,  and  there  was  no  difficulty  in  introducing  the  stomach- 
tube  or  bougie,  although  the  patient  still  complained  of  some  subjective 
disturbances  in  swallowing,  doubtless  due  to  the  dilatation  of  the  oesoph- 
agus,— the  food  entering  the  stomach  largely  from  gravitation,  rather  than 
from  the  peristaltic  action  of  the  musculature  of  the  oesophagus. 

Six  months  after  the  first  treatment,  the  patient  had  gained  24  pounds 
in  weight,  had  practically  no  difficulty  in  swallowing,  and  her  general  health 
was  greatly  improved.] 

2.    Hysterical  Spasm  of  the  (Esophagus 

Case  2. — Mrs.  Emma  E.,  26  years  old,  suffered  from  hysterical  spasm 
of  the  oesophagus,  with  secondary  dilatation. 

For  about  one  year,  the  patient  had  complained  of  cramp-like  pains 
in  the  region  of  the  xiphoid  process,  and  of  ^•omiting  immediately  after 
swallowing.  These  symptoms  had  gradually  increased  in  severity  until 
eight  weeks  previous,  at  which  time  the  patient  vomited  about  a  pint  of 
blood.     She  had  lost  20  pounds  in  weight.     She  had  been  pregnant  three 


DISEASES  OF  THE  (ESOPHAGUS  67 

years  previous.  No  menses  for  one  year.  The  patient  presented  a  olassieal 
case  of  hysteria.  It  was  possible  to  introduce  the  largest-sized  sound,  after 
waiting  a  few  moments  to  allow  the  spasm  of  the  oesophagus  to  relax.  The 
stomach-contents  were  normal,  free  hydrochloric  acid  being  present,  and 
the  total  acidity  was  40.  After  several  treatments  had  been  given,  the 
patient  became  jaundiced,  and  entered  a  hospital.  According  to  the  state- 
ment of  the  physician,  a  laparotomy  was  performed  at  the  urgent  recjuest 
of  the  patient,  and  with  permanently  good  results. 

Foreign  Bodies 

Often  coins,  pieces  of  bone,  fragments  of  meat,  and  espe- 
cially false  teeth,  accidently  get  into  the  oesophagus. 

Foreign  bodies  of  smallsize  may  be  best  removed  by  the 
well-known  "coin-catcher"  forceps;  and  those  of  larger  size, 
with  the  oesophageal  forceps  of  Rosenheim  and  the  oesophago- 
scope,  which  would  best  be  done  by  the  specialist,  or  one 
familiar  with  its  use. 

It  is  necessary  to  recall  the  fact  that  patients,  especially 
hysterical  persons,  frequently  insist  that  they  have  swallowed 
teeth  or  other  objects  in  their  sleep,  which  they  miss  upon 
awakening  in  the  morning.  Often,  through  nervousness  and 
anxiety,  such  patients  complain  of  pain  in  the  oesophagus. 
The  introduction  of  a  large,  soft  stomach-tube  will  usually 
prove  the  fears  of  the  patient  to  be  without  foundation. 

If  a  patient  has  actually  swallowed  a  foreign  body  which 
has  already  entered  the  stomach,  the  physician  should  not 
administer  laxatives,  but  instead  should  prescribe  the  so- 
called  "potato-cure."  The  patient  should  live  for  several 
days  almost  exclusively  on  mashed  potatoes,  which  should 
be  made  rich  by  the  addition  of  cream  and  butter.  Only 
bread  and  butter  may  be  allowed  in  addition.  This  form  of 
diet  surrounds  the  foreign  body  with  masses  of  cellulose,  which 
facilitates  its  passage  without  injury  to  the  intestinal  wall. 
In  case  the  bowels  do  not  move,  the  physician  should  pre- 
scribe a  high  enema  of  oil. 

The  physician  should  never  neglect  to  make  a  digital 
examination  of  the  rectum,  in  which  a  foreign  body  often 
remains  impacted. 


68 


DISEASES  OF  THE  DIGESTIVE  CANAL 


Rosenheim  rccommeiuls,  in  every  case,  the  administra- 
tion of  morphine  to  relax  the  musculature  of  the  oesophagus 
and  to  allow  the  foreign  body  to  pass  into  the  stomach. 

NEUROSES   OF   THE   (ESOPHAGUS 

Uncomplicated  neuroses  of  the  oesophagus  are  rare. 
The  neuroses  most  important  to  the  general  practitioner  are 
nervous  eructation  and  hypersesthesia  of  the  oesophagus, 
which  occur  most  frequently  in  hysterical  individuals. 


Fig.  19. 


^ 


1.   Obturator.     2.  Qilsophagoscope.     3.   Coin  catcher  and  foreign  body  forceps. 

Nervous  eructation  manifests  itself  by  loud,  explosive 
eructations  which  can  be  easily  heard  in  an  adjoining  room, 
and  are  extremely  annoying  to  both  patient  and  friends. 
These  eructations  may  be  explained  by  the  fact  that  the 
patient  alternately  swallows  and  eructates  air.  The  attacks 
occur  paroxysmally,  about  like  whooping-cough.  Usually 
no  other  objective  symptoms  of  the  disease  are  present,  with 
the  exception  of  signs  of  a  general  neurasthenia  or  hysteria. 


DISEASES  OF  THE  (ESOPHAGUS  69 

I  have  observed  that  many  patients  are  reheved  of  these 
explosive  eructations  by  a  sharp  pressure  against  a  circum- 
scribed area  of  the  epigastrium. 

The  diagnosis  of  nervous  eructation  is  very  easy  if  the 
patient  has  an  attack  in  the  presence  of  the  physician.  Other- 
wise, he  is  entirely  dependent  upon  the  history  of  the  trouble 
in  making  the  diagnosis. 

The  treatment  is  partially  general,  having  in  view  the 
restoration  of  the  nervous  system  to  its  normal  tone;  and 
partially  suggestive,  consisting  of  endofaradization  of  the 
oesophagus  with  a  mild  current.  In  addition  to  the  above, 
the  patient  should  generally  be  given  one  or  two  grams  of 
sodium  bromide  in  a  cup  of  cold  valerian  tea  night  and  morn- 
ing, carbonic  acid  baths,  massage  of  the  entire  body,  and 
whenever  possible  a  change  of  scene  and  climate. 

The  wedging  of  an  ordinary  cork  between  the  upper  and 
lower  jaws, — a  procedure  recommended  by  Mathieu, — is 
often  useful  in  the  treatment  of  an  attack,  because  the  patient 
cannot  swallow  when  his  mouth  is  open.  This  should  be  done 
for  one-half  hour  three  times  daily. 

Hyperassthesia  of  the  CEsophagus 

In  hypersesthesia  of  the  oesophagus,  deglutition,  as  well 
as  the  peristaltic  waves  of  the  oesophagus  which  follow  the 
swallowing,  are  disagreeable  to  the  patient.  The  sensation 
is  described  as  a  painful  drawing  feeling,  beginning  above 
and  extending  downward.  Affections  of  this  kind  are  usually 
very  stubborn  to  treatment,  and  require  a  great  deal  of 
perseverance  on  the  part  of  the  physician  to  bring  about  a 
cure.  The  use  of  narcotics,  milk  of  almonds,  and  the  treat- 
ment of  general  neuroses,  are  indicated. 

CLINICAL    CASES 
1.  Nervous  Eructation 

Case  1. — Mrs.  M,.,  36  years  old,  the  wife  of  a  merchant,  had  for  three 
years  suffered  from  loud  eructations  when  emotionally  excited.  When  her 
mind  was  diverted  from  herself,  she  was  always  better.  The  patient  was 
naturally  much  embarrassed  by  these  eructations  when  attending  to  social 


70  DISEASES  OF  THE  DIGESTIVE  CANAL 

duties.  Striking  the  epigastrium  would  gixc  her  relief.  Endofaradization 
of  the  oesophagus,  the  use  of  broniiile,  and  a  sanatorium  treatment  bad  been 
ineffeetually  tried. 

I  prescribed  valerian  tea,  with  one  or  two  grains  of  bromide  of  potas- 
sium, morning  and  evening;  and  30  drops  of  the  following  mixture  three 
times  a  day  after  meals,  taken  on  sugar,  and  followed  by  absolute 
mental  quiet. 

I^     Tincturse  belladonnae  foliorum,  gr.  Ixxx     5.0 
Spiritus  menthse  piperita3,  o  iiss  10.0 

Tincturse  Valerianae,  oiv  15.0 

During  the  following  five  months,  the  patient  was  very  much  relieved, 
at  the  end  of  which  time,  owing  to  overwork  and  the  recurrence  of  an  old 
parametritis,  there  was  a  return  of  the  nervous  eructations. 

C.\SE  2. — Alvin  VV.,  20  years  old,  a  business  man,  had  suffered  from 
ner^'ous  eructations,  together  with  sexual  neiu-asthenia.  After  treatment 
with  arsenic,  and  aqua  amygdalse  amarte,  combined  with  constitutional 
treatment,  baths,  etc.,  the  patient's  condition  improved. 

2.  Neurosis  of  the  (Esophagus 

Case  3. — Agnes  S.,  25  years  old,  the  wife  of  a  working  man,  had,  for 
two  months  following  cessation  of  lactation,  suffered  occasional  pain  behind 
the  sternum  after  swallowing  solid  foods.  For  three  days,  the  pain  had 
occurred  even  after  using  liquid  foods.  The  entire  CBSophagus  was  painful 
and  the  attacks  of  pain  lasted  usually  about  two  or  three  minutes.  A  sound 
could  be  introduced  without  much  trouble,  although  it  was  painful  to  the 
patient.  After  treatment  consisting  of  bromide  and  valerian  tea,  the  dif- 
ficulty disappeared. 

3.  "Hysterical  Spasms  of  the  (Esophagus" 

Case  4. — Wally  B.,  a  servant  girl  28  years  old,  had  suffered  from 
cramp-like  pains  in  the  abdomen  and  sacral  region,  and  from  a  drawing  pain 
beginning  at  the  upper  and  extending  to  the  lower  extremity  of  the  oesophagus, 
occurring  immediately  after  swallowing  solids  or  liquids.  These  symptoms 
were  relieved  in  about  fifteen  minutes  by  the  patient's  bending  forward  with 
pressure  exerted  upon  the  epigastrium.  The  patient  had  a  sensation  as  if 
the  food  remained  in  the  oesophagus  instead  of  entering  the  stomach.  Ten 
months  prior  to  the  beginning  of  the  trouble,  the  patient  had  an  accident, 
since  which  time  she  had  been  very  excitable  and  nervous.  Patient  was 
examined  only  once,  because  she  did  not  return  for  treatment. 

FINAL    REMARKS 

In  regard  to  the  diagnostic  and  therapeutic  peculiarities 
of  the  diseases  of  the  oesophagus,  many  are  of  interest  and 


DISEASES  OF  THE  STOMACH  71 

importance  to  the  specialist  only,  such  as  varices,  acute  and 
chronic  catarrh,  infections,  injuries,  corrosions,  phlcgmona, 
etc.  The  physician  is,  therefore,  referred  to  the  well-known 
text-books  of  Rosenheim,  Fleiner,  Krauss,  etc.,  for  a  full 
discussion  of  the  subject,  as  a  recital  of  all  their  details  would 
overstep  the  limits  of  this  book. 

It  will  be  pointed  out  here  merely  that  there  are  dangers 
associated  with  the  introduction  of  sounds  into  the  oesophagus, 
— particularly  hard,  inflexible  instruments,  such  as  the 
cesophagoscope.  Extreme  caution  must  be  urged,  for  a  too- 
brusque  manipulation  has  frequently  caused  perforation, 
suppurative  mediastinitis,  and  even  sudden  death. 

Diseases  of  the  Stomach 

CLINICAL    REMARKS 

Of  the  three  functions  of  the  stomach, — secretion,  absorp- 
tion, and  motility, — the  most  important  is  motility.  Absorp- 
tion from  the  stomach  is  nil;  water  and  other  fluids  are  not 
absorbed  until  they  enter  the  intestine;  only  a  few  of  the  salts, 
alcohol,  and  medicaments  are  taken  up  by  the  lymph-vessels 
of  the  stomach.  Hence,  from  the  practical  standpoint,  it  is 
needless  to  discuss  the  absorptive  ability  of  the  stomach,  so 
far  as  it  is  concerned  in  the  nourishment  of  the  human  body. 

The  secretory  functions  of  the  stomach  are  not  absolutely 
necessary  to  the  existence  of  civilized  man.  The  investigation 
of  Von  Noorden  has  proven  that  a  person  can  feel  perfectly 
well,  and  can  be  well-nourished,  when  there  is  a  total  absence 
of  gastric  juice.  The  intestine  is  able  to  maintain  completely 
the  nutrition  of  the  body,  so  long  as  sufficient  nourishment 
enters  it  from  the  stomach. 

Since  the  ingenious  experiments  of  Knud  Faber,  of 
Copenhagen,  we  are  better  informed  concerning  the  physio- 
logical functions  of  the  stomach.  It  serves  less  for  the  disinfec- 
tion of  the  food  than  has  previously  been  supposed, — as 
disinfection  might  have  been  accomplished  equally  well  by  an 
alkaline  secretion.    The  gastric  juice  is  much  more  concerned 


72  DISEASES  OF  THE  DIGESTIVE  CANAL 

with  the  digestion  of  bones  and  connective  tissue,  and  with 
the  breaking  up  and  division  of  resistant  carbohydrates,  of 
vegetal)lcs,  etc. 

Such  beasts  of  prey  as  tigers  or  snakes,  which  h\e  exclusi\-cly  on 
flesh-foods  and  bones,  would  soon  die  from  perforation-peritonitis  if  it  were 
not  for  the  abihty  of  the  gastric  juice,^which  in  carnivora  is  of  double  the 
strength  it  is  in  man, — to  rob  the  ingestion  of  bones  of  danger  to  the  animal. 
Civilized  man  might  certainly  exist  without  the  aid  of  the  gastric  acids,  since 
he  has  learned  to  select  his  food  with  the  greatest  care  and  to  soften  and  make 
it  more  digestible  by  cooking  it. 

Indispensably  necessary  to  the  normal  nutrition,  however, 
is  an  undisturbed  motility  of  the  stomach,  i.e.,  the  ability  of 
the  stomach  to  expel  the  chyme  into  the  duodenum  normally. 
The  reader  is  referred  to  the  description  of  the  various  tests 
of  motility, — the  test-dinner,  the  test-supper,  the  remnant- 
test,  etc., — in  the  foregoing  General  Section. 

Practically  speaking,  the  motor  function  of  the  stomach 
is  seriously  impaired  only  when  there  is  mechanical  obstruc- 
tion at  its  outlet.  The  mechanical  action  of  this  function  may 
be  compared  with  that  of  the  heart:  as  the  left  ventricle 
becomes  hypertrophied  and  dilated  in  diseases  of  the  aortic 
valves,  that  portion  of  the  stomach,  i.e.,  the  antrum  pylorus, 
which  lies  behind  an  obstruction, — for  instance,  a  cicatricial 
stenosis  of  the  pylorus, — becomes  hypertrophied  and  dilated. 
This  is  followed  finally  by  dilatation  of  the  entire  stomach. 
The  obstruction  at  the  pylorus  will  at  first  be  compensated 
exactly  the  same  as  in  the  case  of  the  heart. 

If,  however,  the  obstruction  is  too  marked,  or  if  the 
demands  upon  the  organ  become  too  great,  there  occurs, — 
exactly  as  in  disease  of  the  heart, — a  stage  of  disturbed  com- 
pensation, i.e.,  an  insufficiency  of  its  motility. 

Every  insufficiency,  is,  therefore,  an  obstruction  of  the 
pylorus  in  the  stage  of  disturbed  compensation. 

Disturbances  of  motility  caused  by  factors  other  than 
those  of  a  mechanical  nature  are  exceedingly  rare, — occurring 
only  after  acute  injuries,  intoxications,  etc.  Sometimes  the 
same  factors  that  lower  the  general  health  of  the  patient, 


DISEASES  OF  THE  STOMACH 


7S 


such  as  neurasthenia,  anaemia,  and  chronic  malnutrition, 
impair  the  motihty  of  the  stomach;  but  this  occurs  only  to 
a  minimum  degree,  so  that  in  such  cases  insufficiency  of 
motility  never  follows. 

For  further  details,  the  reader  is  referred  to  the  chapter 
on  Dilatation  of  the  Stomach. 

The  position  of  the  stomach  is,  generally  speaking,  unim- 
portant, so  far  as  diagnosis  is  concerned.   The  accurate  determi- 


Diagram  showing  different  positions  of  the  stomach.    C,  typical  vertical  stomach;  u,  umbilicus; 

sjj.c,  vertebral  column. 

nation  of  the  position  of  its  greater  curvature  is  of  value  only 
in  locating  tumors  of  the  stomach  or  of  the  neighboring  organs. 
On  the  other  hand,  this  is  quite  unimportant  in  differ- 
entiating between  organic  and  functional  affections  of  the 
stomach.  As  already  mentioned,  the  greater  portion  of  the 
stomach  occupies  a  transverse  position  in  the  left  hypo- 
chondrium,  behind  the  left  lobe  of  the  liver,  and  in  persons 
with  normal  habitus,  only  a  small  portion  of  it  lies  against  the 
anterior  abdominal  wall.    But  in  persons  with  habitus  enterop- 


74  DISEASES  OF  THE  DIGESTIVE  CANAL 

licus,  the  stomach  stands  almost  vertical,  with  the  greater 
portion  of  it  lying  against  the  anterior  abdominal  wall.  The 
more  emaciated  and  relaxed  the  abdominal  wall  is, — for 
instance,  after  pregnancy, — the  more  this  will  be  the  case. 

The  position  of  the  lower  border  of  the  greater  curvature 
of  the  stomach  indicates,  therefore,  absolutely  nothing  con- 
cerning its  motility,  nor  whether  dilatation  exists. 

Splashing  sounds  in  the  epigastrium  are  only  evidence 
of  a  relaxation  of  the  abdominal  walls,  and  of  a  considerable 
portion  of  the  stomach  lying  in  contact  with  the  abdominal 
wall;  they  have  no  pathological  significance,  and  have  nothing 
at  all  to  do  with  dilatation  of  the  stomach,  except  when  they 
occur  in  a  fasting  stomach. 

Especial  attention  should  be  given  to  the  habitus,  because 
this  has  a  marked  bearing  on  the  question  as  to  whether  an 
organic  or  a  functional  stomach-affection  exists. 

In  general,  functional  stomach  and  intestinal  diseases 
are  found  in  persons  with  habitus  enteropticus ,  while  organic 
diseases  of  the  digestive  organs  occur  more  frequently  in 
persons  with  normal  habitus.  Of  course,  exceptions  to  these 
rules  often  occur;  for  instance,  chlorotic  ulcer  is  occasionally 
found  in  a  woman  with  habitus  enteropticus;  and  nervous 
dyspepsia,  in  patients  who  have  normal  habitus. 

In  doubtful  cases,  where  the  examiner  does  not  know 
whether  a  neurosis  of  the  stomach  or  a  gastric  catarrh  or 
ulcer  exists,  he  should  satisfy  himself  as  to  the  habitus;  if 
an  enteroptosis  exists,  he  should  not  prescribe  local  measures 
to  the  stomach,  but  a  general  treatment.  This  precaution 
is  especially  needed  in  cases  of  young  women  up  to  the  age  of 
twenty,  because  it  is  at  this  period  of  life  that  a  large  number 
of  patients  are  treated  for  ulcer  who  are  really  sufi'ering  from 
gastric  neuroses,  and  vice  versa. 

It  must  be  added  here  that  quite  a  large  number  of 
patients  have  a  combined  functional  and  -organic  affection 
of  the  stomach.  A  functional  dyspepsia  may  be  associated 
with  an  organic  disease  of  the  digestive  tract;  for  instance, 
with  acid  gastritis,  intestinal  catarrh,  gall-stones,  cancer,  etc. 


DISEASES  OF  THE  STOMACH  75 

I  take  this  opportunity  to  mention  that  cancer  usually  attacks  those 
persons  who,  up  to  the  time  of  their  affection,  have  always  had  excellent 
digestion,  excepting  where  the  malignant  affection  has  followed  chronic 
ulcer.  The  probable  reason  for  this  fact  is,  that  such  persons  have  not  made 
a  careful  choice  of  their  diet  (as  persons  suffering  from  poor  digestion  are 
obliged  to  do),  and  have  for  years  eaten  rich;  indigestible  foods,  especially 
much  raw  fruit  and  coarse  vegetables  such  as  cabbage  and  turnips.  This 
observation  is  equally  as  applicable  to  the  parasitic  as  to  the  mechani- 
cal theory  of  the  origin  of  carcinoma. 

There  is  an  intimate  relationship  between  diseases  of  the 
stomach  and  those  of  the  intestine.  The  recognition  and  knowl- 
edge of  this  association  will  prove  of  practical  importance  to 
diagnosis, — especially  for  the  direction  of  the  rational  therapy. 

Impaired  gastric  secretion,  for  instance,  is  very  frequently 
the  cause  of  chronic  intestinal  catarrh.  In  such  a  case,  the 
gastric  contents  are  not  sufficiently  chymified,  and  enter  the 
intestine  in  this  undigested  state.  In  the  course  of  a  few  years 
this  causes  chronic  enterocolitis. 

It  is  also  true  that  intestinal  catarrh, — whether  associated 
with  constipation  or  with  diarrhoea, — very  frequently  produces 
gastric  dis-turbances, — loss  of  appetite,  neuroses  of  the  stom- 
ach, eructation,  distention  and  pressure  in  the  abdomen, — 
as  a  result  of  the  fermentation  of  food  and  the  formation  of 
gas  in  the  coils  of  the  intestines. 

There  exists,  likewise,  a  close  relationship  between  diseases 
of  the  digestive  tract  and  those  of  other  organs  of  the  body. 
The  general  nutrition  of  the  patient  suffers  after  a  long-con- 
tinued disease  of  the  digestive  canal;  but  impairment  of 
digestion  is  also  caused  by  primary  affections  of  the  lungs, 
heart,  spinal  cord,  kidneys,  liver,  and  sexual  organs. 

It  is  often  difficult  to  determine  which  is  the  primary 
and  which  is  the  secondary  affection.  For  instance,  in  a 
patient  who  suffers  from  a  catarrhal  condition  of  the  apex 
of  one  of  the  lungs,  and  from  chronic  dyspepsia,  the  physician 
is  often  at  loss  to  know  whether  the  chronic  dyspepsia  is  the 
cause  or  the  result  of  the  lung-affection.  In  such  cases,  only 
continued  observation  of  the  patient  will  render  the  diagnosis 
positive. 


76  DISEASES  OF  THE  DIGESTIVE  CANAL 

PRELIMINARY    REMARKS    ON    DIAGNOSIS 

The  chief  task  of  the  diagnostician  consists  in  differ- 
entiating organic  from  functional  disorders  of 
the  digestive  tract.  His  success  depends  upon  being  able  to 
make  this  diagnostic  distinction  correctly,  for  the  entire 
treatment  of  the  case  will  be  governed  thereby. 

If  tlie  anamnesis  has  been  rationally  obtained,  the  ex- 
aminer will  usually  be  able  at  once  to  make  the  differentiation 
between  organic  and  functional  affections.  In  many  cases, 
this  is  possible  only  after  the  physical  and  chemical  examina- 
tion; and  in  still  other  cases,  the  full  diagnosis  can  be  made 
only  after  continued  observation  of  the  patient. 

Since  this  book  is  designed  especially  for  the  use  of  the 
general  practitioner,  only  those  methods  are  discussed,  in 
detail,  which  do  not  require  elaborate  preparation  and  tcch- 
nic  for  their  execution. 

Unfortunately,  the  time  has  not  yet  passed,  when  every 
chronic  stomach  affection  that  has  not  been  diagnosed  "gas- 
tric ulcer,"  "cancer,"  or  "dilatation  of  the  stomach,"  is 
inaccurately  classified  under  the  general  heading  of  "chronic 
catarrh  of  the  stomach."  Leube  was  the  first  to  initiate  a 
departure  from  this  classification.  He  introduced  the  term, 
"nervous  dyspepsia." 

The  fact  should  be  strongly  emphasized  at  the  beginning 
of  this  discussion,  that  a  large  majority  of  stomach-affections 
are  of  a  functional  nature,  and  that  the  minority  only  are 
attributable  to  organic  changes  of  the  stomach. 

Another  frequent  and  incorrect  diagnosis  is  that  of 
"dilatation  of  the  stomach."  This  diagnosis  is  very  often  and 
wrongly  made,  when  splashing  sounds  are  heard  in  the  epi- 
gastrium and  extend  to  below  the  umbilicus. 

It  is  evident  that  in  most  of  such  cases  there  is  only  a 
displacement  of  the  stomach  downward, — a  "gastroptosis," 
or  the  so-called  "vertical"  position  of  the  stomach,  caused  by 
a  relaxation  of  the  abdominal  walls,  etc. 

Acute  dilatation  of  the  stomach  rarely  occurs,  as  we  shall 
see  below. 


DISEASES  OF  THE  STOMACH  77 

A  third  very  frequent  diagnosis  is  "nervous  cramps," 
or  "contractions  of  the  stomach." 

In  most  of  these  cases,  we  have  to  do  rather  with  gall- 
stone cohc,  intestinal  cohc,  or  with  pylorospasm  resulting 
from  ulcer.  Crampy  or  colicky  pains  of  nervous  origin  prac- 
tically never  occur  unless  in  the  most  severe  cases  of  hysteria, 
or  as  the  gastric  crises  of  locomotor  ataxia. 

In  general  work,  therefore,  it  is  best  not  to  make  a  diag- 
nosis of  "nervous  contraction"  or  "spasms  of  the  stomach." 

One  of  the  fundamentals  in  diagnosis  is  the  considera- 
tion of  the  statement  of  the  patients,  as  to  whether  they  have 
actual  pain  or  only  pressure  in  the  stomach.  It  is 
quite  natural  for  a  member  of  the  laity  to  say  that  he  has 
"pain,"  in  speaking  of  any  kind  of  discomfort;  and  only  a 
very  accurate  examination  will  enable  the  physician  to  arrive 
at  a  correct  conclusion  as  to  the  nature  of  the  pathological 
conditions  present. 

It  is  on  this  account  that  patients  should  be  made  to 
describe  their  subjective  symptoms  with  accuracy,  since  actual 
pain  scarcely  ever  occurs  in  nervous  or  functional  affections  of 
the  stomach  and  intestine.  Functional  disorders  are  accompa- 
nied by  disagreeable  sensations,  such  as  pressure,  distention, 
loss  of  appetite,  nausea,  etc.,  rather  than  by  actual  pain. 

On  the  other  hand,  actual,  severe,  cramp-Hke,  griping, 
burning,  cutting,  gnawing  pains,  which  may  radiate 
from  the  stomach  to  the  back,  to  either  side,  upwards  or 
downwards,  are  to  be  found  almost  exclusively  in  organic 
diseases  of  the  stomach,  intestine,  or  neighboring  organs,  such 
as  the  heart,  spinal  cord,  kidneys,  liver,  gall-bladder,  uterus, 
urinary  bladder,  or  pancreas. 

Actual  pain,  therefore,  whether  persistent  or  period- 
ical, occurs  almost  exclusively  in  organic  diseases. 

Buch  has  proposed  the  term  "  epigastralgia''  to  designate 
paroxysms  of  pain  which  occur  in  the  epigastrium.  The  use 
of  this  word  should  be  encouraged,  because  the  expression 
"epigastralgia"  is  not  specific,  while  "gastralgia"  specific- 
ally indicates  that  the  location  of  pain  is  in  the  stomach. 


78  DISEASES  OF  THE  DIGESTIVE  CANAL 

We  shall,  thcroforo,  in  this  book  spocak  of  '^cpigastral- 
gia"  when  referring  to  cranip-likc  pain  occurring  in  the  e|)i- 
gastrium. 

The  diagnostic  significance  of  epigastralgia  is  as  follows: 

In  ulcer  of  the  pylorus,  epigastralgia  occurs  regularly 
at  a  certain  time  after  eating,  usually  from  one  to  four  hours 
after  the  heav}^  meal  of  the  day;  rarely  as  early  as  thirty 
minutes  after  the  meal,  and  never  sooner. 

Epigastralgia  immediately  after  swallowing  is  usually 
caused  by  ulcer  of  the  oesophagus  or  of  the  cardia.  When 
it  occurs  a  short  time  after  eating,  it  is  evidence  of  intestinal 
colic,  but  is  considered  by  the  patient  as  "stomach-ache" 
or  "cramps." 

Intestinal  colic  is  generally  independent  of  eating,  while 
it  is  modified  by  the  condition  of  the  bowels  and  by  the  escape 
of  gas.     The  pain  is  really  due  to  flatulent  colic. 

Epigastralgia  which  occurs  sporadically  should  always 
suggest  the  presence  of  cholelithiasis. 

If  the  patient  has  only  a  feeling  of  pressure  in  the  epi- 
gastrium, it  is  the  duty  of  the  physician  to  determine  the 
time  when  it  occurs  and  the  kind  of  food  that  causes  it. 
When  pressure  occurs  only  after  eating  solids  and  heavy 
articles  of  diet,  it  is,  as  a  rule,  due  to  chronic  gastritis, — the 
popular  so-called  "chronic  catarrh"  of  the  stomach. 

If  the  pressure  is  dependent  rather  upon  the  quantity 
than  upon  the  quality  of  the  food  eaten,  and  if  the  pressure 
occurs  after  all  foods, — for  instance,  after  the  patient  has 
taken  only  a  plate  of  soup, — a  functional  nervous  stomach- 
affection  exists. 

If  the  patient  suffers  from  pressure  and  distention  when 
awakening  in  the  morning,  and  if  this  pressure  'is  not  limited 
to  the  epigastrium  but  extends  over  the  entire  abdomen,  there 
exists  a  chronic  intestinal  affection,  which  is  the  cause  of  the 
gaseous  distention  of  the  abdomen  and  the  dyspeptic 
symptoms. 

Concerning  vomiting,  the  following  may  be  noted: 
Vomiting  which  occurs  immediately  after  swallowing  suggests 


DISEASES  OF  THE  STOMACH  79 

that  stenosis,  dilatation,  diverticulum  of  the  oesophagus,  or 
a  disease  of  the  cardia,  exists.  Reflex  vomiting, — for  instance, 
in  hysteria,  pregnancy,  affections  of  the  uterus,  cerebral 
disease,  peritonitis,  etc., — occurs  almost  always  within  the  first 
ten  minutes  after  the  meal. 

In  primary  stomach-affections,  vomiting  occurs  some 
time  after  eating, — except  in  acute  gastritis,  when  it  occurs 
shortly  after  a  meal. 

It  is  necessary  to  differentiate  vomiting  from  regurgita- 
tion, i.e.,  the  raising  of  the  chyme  simultaneously  with  eructa- 
tion. Regurgitation  is  not  associated  with  nausea  or  other 
discomfort,  as  in  a  case  of  vomiting;  but  the  patient's  mouth 
is  filled  with  food  from  eructation,  and  he  then  expels  it. 
Frequently  patients,  especiall}^  those  who  eat  hastily,  eructate 
their  food  as  do  the  ruminating  animals,  i.e.,  chew  it  and  swal- 
low it  a  second  time;  such  patients  are  called  ''ruminants." 

Outline  of  the  Systematic  Examination  of  a  Patient  Suffering 
from  a  Qastro=intestinal  Affection 

After  obtaining  an  exhaustive  anamnesis,  which  includes  the  family 
history,  the  personal  history,  the  general  symptoms,  and  the  sjDecial  com- 
plaints referable  to  the  digestive  canal,  the  physician  should  proceed  with 
the  examination. 

He  should  determine  whether  habitus  enteropticus  exists^  should  as- 
certain the  general  nutrition,  and  the  condition  of  the  heart,  lungs,  etc., 
before  examining  the  abdomen. 

Inspection  and  palpation  of  the  abdomen  should  first  be  made.  Pal- 
pation should  be  made  with  the  patient  in  the  dorsal,  right-side  or  left-side 
position, — sometimes  in  the  upright  position  as  in  cases  of  pendulous  abdo- 
men;  in  diseases  of  the  rectum,  in  the  knee-elbow  position. 

The  test-breakfast  is  to  be  given  the  patient  only  in  a  case  where  the 
diagnosis  is  not  established  by  the  anamnesis  and  the  physical  examination. 
The  test-supper  is  to  be  given  in  the  evening,  and  the  stomach  should  be 
washed  out  the  next  morning  before  breakfast  to  determine  whether  stag- 
nation of  food  exists.  After  this,  the  Boas-Ewald  test-breakfast  should  be 
given  and  an  hour  later  be  removed  from  the  stomach.  The  remnants 
obtained  from  the  fasting  stomach  should  be  examined  microscopicalh% 
and  the  test-breakfast  chemically. 

It  is  absolutely  necessary  to  examine  the  faeces,  both  macroscopically 
and  microscopically,  in  intestinal  affections;  and  finally  the  m-ine  should  be 
examined  for  albumin  and  sugar. 


80  DISEASES  OF  THE  DIGESTIVE  CANAL 

SIGNIFICANCE    OF    COATING    ON    THE    TONGUE 

Most  patients  that  suffer  from  chronic  dyspepsia  attach 
a  great  deal  of  importance  to  the  appearance  of  their  tongues. 
Many  physicians  also  think  they  are  able  to  form  a  conclusion 
as  to  the  condition  of  the  stomach  from  the  thickness  of  the 
coating  on  the  tongue.  This  is  an  error.  A  coated  tongue 
and  affections  of  the  stomach  are  only  indirectly  related.  The 
tongue  is  always  coated  if  the  patient  does  not  chew  his  food, 
or  if  he  masticates  hurriedly;  the  reason  for  this  being  that 
mastication  mechanically  cleanses  the  tongue.  For  this  reason 
the  tongue  is  always  heavily  coated  if  there  is  no  appetite,  as 
in  the  case  of  acute  diseases,  while  in  chronic  diseases,  when  the 
patient  is  masticating  solids  several  times  a  day,  the  tongue 
will  show  scarcely  any  coating,  though  he  may  be  suffering 
from  either  a  functional  or  an  organic  disease  of  the  stomach.* 

INTRODUCTORY  THERAPEUTIC  REMARKS 

In  prescribing  for  a  gastro-intestinal  disorder,  the  physician 
should  never  neglect  to  give  the  patient  a  written  diet-list. 
It  is  inexact  and  inadvisable  to  generalize  in  prescribing  a 
patient's  diet.  He  should  be  told  what  he  must  eat,  rather 
than  what  he  must  not  eat.  The  times  for  eating  should  also 
be  definitely  stated  on  the  diet-list,  as  well  as  the  time  for 
mineral  waters,  medicines,  enemata,  baths,  the  hours  of  rest 
and  exercise,  and  in  short,  all  directions  that  will  regulate  the 
daily  life   of  the   patient. 

It  is  always  well  to  give  as  little  medicine  as  possible, 
especially  to  patients  belonging  to  the  cultured  classes  of 
society.  Where  two  different  pharmaceutical  effects  are 
desired,  the  physician  may  best  combine  the  medicament  with 
some  household  remedy.  For  instance,  he  may  give  a  bitter 
or  potassium   bromide   with  a  soothing  tea   mixture;    or  he 

*[  Mailer,  in  the  "  Miinchner  M edizinische  Wochenschrift,"  1900,  No.  33, 
and  Fuchs,  in  "  Ueber  den  Zungenbelag  und  seine  Bedeutung,"  Wiirzburg,  1898, 
were  the  first  to  make  the  observation  that  62  per  cent,  of  the  healthy  persons 
that  they  examined  had  coated  tongues;  and  that  caries  of  the  teeth,  stomatitis 
or  catarrhal  pharyngitis,  etc.,  existed  in  66  per  cent,  of  young  persons  whose 
tongues  were  coated .] 


DISEASES  OF  THE  STOMACH  81 

may  prescribe  the  medicine  before  eating  and  the  household 
remedy,  bicarbonate  of  soda,  after  the  meal. 

The  physician  should  always  avoid,  so  far  as  possible, 
overloading  the  patient  with  therapeutic  procedures  if  he  is 
obliged  to  continue  his  occupation.  It  is  generally  a  mistake 
to  forbid,  too  rigorously,  beer,  wine,  tobacco,  and  other  com- 
forts and  luxuries.  The  physician  should  be  inflexible  and 
strict  with  those  patients  only  whose  maladies  are  the  result 
of  their  unhygienic  manner  of  living,  inebriety,  overwork, 
irregular  hours,   overeating,   etc. 

He  must,  first  of  all,  be  sure  that  he  will  be  able  to  treat 
the  case  successfully  without  institutional  or  clinical  treat- 
ment. If  he  is  in  doubt,  he  should  first  institute  ambulatory 
or  office  treatment;  for  instance,  in  the  case  of  a  patient  who 
is  suffering  from  ulcer  of  the  stomach  and  who,  on  account  of 
his  poverty,  is  unable  to  choose  his  mode  of  living.  It  is  always 
preferable,  however,  for  such  a  case  to  enjoy  the  advantages 
of  the  rest-cure  from  the  first. 

In  chronic  nervous  dyspepsia  accompanied  with  marked 
emaciation,  and  where  a  general  weakening  of  the  entire 
constitution  of  the  patient  is  responsible  for  the  dyspepsia, 
the  physician  should  advise  sanatorium  treatment  for  from  four 
to  six  weeks,  if  possible,  or  a  change  of  climate,  because  a 
large  number  of  these  patients  are  cured  only  when  they  are 
removed  from  conditions  and  surroundings  which  were  the 
cause  of  the  dyspepsia,  and  are  transferred  to  more  favorable 
conditions  where  they  may  have  the  advantages  of  the  proper 
nourishment,  rest,  and  change  of  scene. 

A  very  large  proportion  of  dyspeptics  are  sacrifices  to 
the  bad  social  conditions  under  which  they  live;  too  much 
work,  too  little  recreation,  improper  nourishment,  unhygienic 
dwellings,  and  the  competition  for  bread, — while  the  better 
classes  suffer  from  too  many  enervating  pleasures. 

The  medical  attendant  in  treating  organic  stomach  and 
intestinal  diseases  should  not  direct  all  of  his  therapeutic 
measures  against  the  local  affection,  but  should  at  the  same 
time  treat  the  general  condition. 

6 


82  DISEASES  OF  THE  DIGESTIVE  CANAL 

Ordinarily  a  restricted  diet,  or  in  rare  cases  a  total  abstin- 
ence from-  food  per  os,  is  indicated  in  organic  diseases  of  the 
stomach  and  intestine.  Nervously  exhausted  individuals, 
however,  usually  require  a  nourishing  and  strengthening  line 
of  therapeutic  measures.  The  physician,  therefore,  is  obliged 
frequcntl}"  to  prescribe  a  combination  of  a  nourishing  and  of  a 
so-called  ''sparing"  diet;  for  example,  the  diet  must  be  suitable 
for  a  primary  chronic  catarrh  of  the  stomach  or  intestine  but 
must,  at  the  same  time,  be  sufficientl}^  nourishing  to  maintain 
the  strength  and  vigor  of  the  patient.  In  such  a  case,  there- 
fore, the  physician  should  prescribe  a  combined  gastritis- 
fattening  diet.  Other  examples  might  here  be  cited,  but  the 
subject  will  be  dealt  with  in  detail  in  the  section  on  Dietetics. 

There  is  only  one  chronic  disease, — namely,  gastric  ulcer, 
— in  which  the  diet  from  the  beginning  may  contain  fewer 
calories  than  are  required  to  maintain  the  weight  of  the  body. 
If  a  patient  who  is  undergoing  the  rest-cure  receives  daily  35 
to  40  calories  per  kilogram  of  body-weight,  he  will  generally 
improve  in  nutrition. 

It  is  well  known  that  one  gram  of  fat  furnishes  about  9  calo- 
ries, and  that  one  gram  of  albumin  or  one  gram  of  carbohydrate 
furnishes  about  4  calories.  Cream  contains,  on  an  average, 
20  per  cent,  of  fat.  In  one  litre  of  cream,  therefore,  there  are 
200  grams  of  fat,  which  are  sufficient  to  furnish  the  entire 
daily  food-requirements  of  a  weak,  bed-ridden  patient.  Milk, 
therefore,  except  in  obesity,  should  be  the  basis  upon  which 
the  complete  diet  of  the  patient  is  planned. 

A.  ORGANIC  DISEASES  OF  THE  STOMACH 

Acute  and  Chronic  Gastric  Catarrh 

Perhaps,  of  all  stomach  diseases,  catarrh  of  the  stomach 
is  most  frequently  diagnosticated  where  it  does  not  exist. 
If  the  physician  is  unable  to  make  a  correct  diagnosis  of  a 
disturbance  of  digestion,  he  should  be  temporarily  satisfied 
with  the  diagnosis  ''chronic  dyspepsia,"  indicating  mercl}^ 
that  the  patient  is  suffering  from  an  affection  which  is  accom- 
panied by  digestive  derangements. 


DISEASES  OF  THE  STOMACH  83 

The  diagnosis  of  chronic  gastritis  cannot  be  established 
until  the  examiner  has  ascertained  that  there  is  a  permanent 
departure  from  the  normal  in  the  secretion  of  gastric  juice, 
which  is  associated  with  pathological  and  anatomical  altera- 
tions of  the  mucous  membrane  of  the  stomach.  The  same 
principle  should  guide  the  physician  in  cases  of  acute  gastritis, 
which  is  very  frequently  confused  with  acute  dyspepsia  and 
reflex  stomach-affections  in  neurotic  individuals. 

Acute  Gastritis 

Etiology. — The  causes  of  acute  gastritis  are:  over- 
loading the  stomach  with  indigestible  food;  poisoning  by  such 
tainted  foods  as  sausage,  pastry,  meat,  etc.;  and  infections. 

Mycotic  acute  gastritis  is  that  form  of  inflammation  of 
the  stomach  generally  called  gastric  fever.  Its  specific  cause 
is  not  accurately  known. 

Gastritis  caused  by  parasitic  infections  belongs  to  this 
form  of  stomach-inflammation. 

Acute  gastritis  is  most  frequently  caused  by  overload- 
ing the  stomach  in  summer  with  fruit  or  cucumber  salad, 
in  combination  with  beer-drinking,  and  in  winter  by  rich 
luncheons  and  dinners. 

Enteritis  is  almost  always  associated  with  acute  gas- 
tritis;   constipation,  rarely. 

Acute  inflammation  of  the  stomach  is  produced  by  a 
much  milder  irritation  in  children  than  in  adults. 

It  is  scarcely  necessary  to  mention  that  the  presence  of 
metallic  and  vegetable  poisons  in  the  stomach  produces  acute 
gastritis,  which  runs  the  same  course  as  simple  gastritis  caused 
by  other  irritants.  Mercury,  acids,  and  alkalies,  and  medica- 
ments such  as  the  balsam  of  copaiba,  extract  of  male  fern, 
etc.,  are  the  most  common  irritants  of  this  class. 

Symptomatology. — The  symptoms  of  acute  gastritis 
consist  of  general  and  local  subjective  disturbances 
and  general  and  local  objective  findings.  The  anam- 
nesis shows  that  the  patient  has  generally  suffered  one  or  two 
days  from  acute  indigestion,  after  which  the  disease  has  set 


84  DISEASES  OF  THE  DIGESTIVE  CANAL 

in  suddenly  with  nausea,  vomiting,  diarrhoea,  lassitude, 
crampy  pains,  and  chills. 

Besides  the  foregoing  appear  the  following  symptoms, 
related  specially  to  the  digestive  tract :  pressure  in  the  stomach, 
distention  and  a  feeling  of  fulness  in  the  epigastrium,  gnawing 
pains  after  eating,  especially  solids;  and  in  case  the  inflam- 
matory process  involves  the  intestine,  crampy  pains  in  the 
abdomen  and  diarrhoea  occur. 

In  his  objective  examination,  the  physician  will  find  the 
patient  pale,  with  the  appearance  of  emaciation,  and  often 
feverish.  Sometimes  there  is  herpes  labialis  and  marked 
local  sensitiveness  to  pressure  over  the  epigastrium  and 
abdomen. 

Frequently  jaundice  and  acute  swelling  of  the  liver  and 
spleen  are  likewise  found. 

The  secretion  of  gastric  juice  is  diminished  or  totally 
lost,  and  the  tongue  is  heavily  coated. 

Diagnosis. — The  diagnosis  of  acute  gastritis  is  usually 
easy,  if  there  is  a  history  of  an  alimentary  derangement  or 
toxic  infection  associated  with  intestinal  disturbances,  A 
differential  diagnosis  should  alwaj^s  be  made  between  acute 
gastritis  and  the  large  number  of  affections  whose  S3^mptoms 
resemble  those  of  acute  gastritis;  namely,  peritonitis,  appen- 
dicitis, incarcerated  hernia,  ileus,  meningitis,  scarlatina,  and 
acute  insufficiency  of  the  stomach. 

The  symptoms  of  the  gastric  crises  of  tabes,  of  reflex 
vomiting  in  pregnancy,  or  of  retroflexion  of  the  uterus,  may 
all  closely  resemble  the  gastric  disturbances  in  acute  gastritis. 
The  physician  will  not  be  likely  to  make  a  mistake  in  the 
diagnosis,  however,  if  he  uses  sufficient  care  in  the  examination 
of  the  patient,  and  if  he  keeps  in  mind  the  possibility  of  the 
presence  of  these  other  diseases. 

Extremely  important  is  the  differentiation  between  acute 
gastritis  and  the  acute  nervous  dyspepsia  which  frequently 
occurs  in  anaemic  and  neurasthenic  patients,  and  is  the  first 
symptom  of  a  chronic  nervous  affection  of  the  stomach,  as 
will  be  shown  in  the  chapter  on  Gastric  Neuroses. 


DISEASES  OF  THE  STOMACH  85 

This  acute  nervous  dyspepsia,  runs  its  course  without 
fever,  herpes  labiahs,  or  diarrhoea.  There  is  no  history  of 
such  causative  factors  as  errors  in  diet,  etc.  It  manifests 
itself  only  by  pressure  in  the  stomach,  a  feeling  of  fulness, 
and  loss  of  appetite. 

Prognosis. — It  is  extremely  rare  for  acute  gastritis  to 
result  unfavorably,  and  then  only  when  it  is  the  outcome  of  a 
severe  infection,  as  in  acute  yellow  atrophy  of  the  liver,  Weil's 
disease,  meat  and  sausage  poisoning,  and  other  intoxications. 

Treatment. — The  fundamental  principles  of  the  treatment 
of  acute  gastritis  are  the  removal  of  the  exciting  cause,  and 
the  sparing  of  the  inflamed  organ.  The  physician  should,  there- 
fore, carefully  wash  out  the  stomach  if  he  is  called  to  the  case 
early,  or  he  should  administer  an  emetic,  especially  to  children. 
The  well-known  tartar  emetic  with  ipecac  is  suitable. 

I^     Antimonii  et  potassi  tartratis,  gr.  f        0.05 
PulverJs  radicis  ipecacuanhse,  gr.  xv      1.0 
M.  et  ft.  chartulae  No.  iii. 

Sig. — One  powder  every  fifteen  minutes  until  vomiting  occurs. 

For  children,  the  physician  should  give,  by  preference, 
wine  of  antimony  in  doses  of  two  to  ten  minims  until  vomit- 
ing results. 

I  give  a  laxative  only  in  cases  where  the  noxious  material 
has  already  left  the  stomach,  and  where  there  is  a  high  fever 
associated  with  constipation.  The  best  laxative  is  castor 
oil.     Calomel  may  be  used  for  children. 

Many  physicians  prescribe  a  laxative  in  every  case  of 
acute  diarrhcea  associated  with  vomiting.  I  consider  this  to  be 
a  mistake,  because  such  treatment  is  unnecessarily  weakening. 

If  the  patient  has  no  fever,  or  only  a  slight  rise  in  tem- 
perature, after  diarrhoea  has  continued  for  a  few  days,  the 
physician  should  not  administer  a  laxative,  but  should  leave 
the  cure  of  the  diarrhcea  to  nature. 

Opium  should  never  be  prescribed,  since  its  use  prevents 
the  evacuation  of  the  offending  material,  and  necessarily 
prolongs  the  course  of  the  infection.  The  use  of  belladonna 
or  atropine  is  much  more  rational  when  there  is  an  intense 


86  DISEASES  OF  THE  DIGESTIVE  CANAL 

irritability  and  liypersesthesia  of  the  intestinal  tract.  In  the 
beginning  of  the  disease,  I  prescribe  the  following  mixture 
if  nausea  and  vomiting  are  prominent  symptoms: 

rj     Acidi  hydroclilorici,  gtt.  16-24         1.0-1.5 
AqiUB  mentluT>  piperittr,  oviss  200.0 

M.  Sig. — One  tablespoonful  every  hour. 

As  an  after-treatment,  I  prescribe  pure  hydrochloric  acid 
every  two  hours,  6  drops  in  a  wineglassful  of  lukewarm  water. 

In  this  affection,  I  have  found  this  mixture  useful,  to 
which,  in  some  cases,  I  add  8.0  [5ii]  of  the  tincture  of  bella- 
donna, together  with  menthol  and  valerian,  as  follows: 

I^     TincturEB  belladonnse  foliorum, 

Spiritus  menthse  piperitse,  aa  oii    a^'i  8.0 
Tincturae  valerianse.,  3iv  16.0 

•  M.    Sig. — Thirty  drops  in  a  cup  of  peppermint  and 

valerian  tea,  three  or  four  times  daily. 

Diet. — The  dietetic  treatment  consists  in  the  "starva- 
tion" diet.  Nothing  but  peppermint  tea,  or  black  tea  with 
cognac,  and  oatmeal  gruel,  should  be  given  for  the  first  two 
days  of  the  illness.  After  nausea  and  vomiting  have  com- 
pletely disappeared,  the  patient  may  be  given  beef  tea,  gruels, 
soups,  and  tea  to  which  sweet  cream  has  been  added;  and  in 
case  of  diarrhoea,  cocoa,  and  spiced  wine  which  is  prepared 
by  cooking  a  red  wine  with  cinnamon  and  cloves  and  diluting 
with  water. 

Solids  should  not  be  permitted  until  after  the  disappear- 
ance of  diarrhoea;  then  gradually  may  be  added  rice  broth, 
oatmeal  porridge,  stale  white  bread  softened  in  liquids,  and 
fresh  butter;  and  later,  pigeon  broth,  calves'  brain,  and  by 
degrees  more  solid  foods,  such  as  pike,  perch,  roast  filet, veal,  etc. 

If   the   bowels   have   been   constipated   for   a   few   days, 
light    vegetables, — spinach,    carrots,    cauhfiower,    asparagus,, 
and  peas, — should  be  prescribed;    and  later,  potatoes,  bread, 
etc.     Fruit  should  not  be  allowed  for  some  time;    nor  acids 
for  still  longer. 

Acute  gastritis  is  entirely  curable  if  the  patient  will  ad- 
here  strictly   to   the    proper   diet;     relapses,    however,    easily 


DISEASES  OF  THE  STOMACH  87 

occur  if  he  assumes  his  ordinary  habits  of  eating  as  soon  as 
the   first  stormy  symptoms  of  the  disease  have  disappeared. 

People  who  hve  at  hotels  and  restaurants  are  especially 
exposed  to  this  danger,  as  it  is  difficult  for  them  to  adhere  to 
a  rational  diet. 

It  is  proper  to  mention  here,  however,  that  at  the  present 
time  there  are  dietetic  restaurants  in  most  of  the  large  cities, 
to  which  the  physician  may  send  such  patients. 

Chronic   Gastritis 

General  Remarks. — Formerly  most  of  the  chronic  dyspep- 
sias were  called  "chronic  gastric  catarrh";  but  since  Leube's 
epoch  -  making  work,  only  that  gastric  affection  is  called 
''chronic  gastritis"  in  which  there  occurs  the  characteristic 
anatomical  alterations  of  the  mucosa. 

Every  chronic  stomach-disease  which  the  anamnesis 
shows  not  to  be  a  case  of  ulcer,  carcinoma,  or  dilatation  of 
the  stomach,  should  be  designated  at  first  as  chronic  dys- 
pepsia. Further  examination  will  determine  whether  an 
organic  or  a  nervous-functional  gastric  affection  exists. 

Chronic  gastritis  is  one  of  those  diseases  of  the  stomach 
in  which  no  positive  diagnosis  can  be  made  without  exam- 
ination of  the  secretions,  because  its  subjective  symptoms 
are  so  manifold  and  so  frequently  similar  to  those  of  other 
chronic  affections  of  the  stomach.  By  the  anamnesis  alone 
the  physician  can  establish,  as  a  rule,  only  a  probable  diag- 
nosis; and  besides,  the  test-breakfast  is  indispensable  in 
differentiating  between  the  various  forms  of  chronic  gastritis. 

The  anatomical  changes  in  chronic  gastritis  are  analo- 
gous to  those  of  nephritis,*  in  which  either  the  parenchy- 
matous or  interstitial  tissues  are  involved. 

The  pathological  process  in  gastritis  rarely  extends  to 
the  muscularis. 

It  is  now  a  well-known  fact  that  besides  the  usual  diminu- 
tion,  or  absence,   of  the  gastric  juice  in  gastritis,  there  are 

*  From  a  pathological  and  anatomical  standpoint  the  classification  is  some- 
what different,  and  approximately  that  of  the  nephritides,  of  which  Hayem  has 
given  a  practical  classification. 


88  DISEASES  OF  THE  DIGESTIVE  CANAE 

cases  in  which  there  is  an  increase  in  the  secretion  of  hydro- 
chloric acid;  indeed,  it  is  even  probable  that  there  is  an  in- 
creased activity  of  the  glandular  structures  in  the  first  stages 
of  all  cases  of  chronic  gastritis.  This  period  of  the  disease 
rarely  comes  under  the  observation  of  the  plwsician,  for  the 
reason  that  the  symptoms  are  then  usually  latent. 

Fig.  21.  Fig.  22. 


mm 


'■MM^^ 


Normal  mucous  membrane  of  the  stomach  Mucous  membrane  in  interstitial  and  atrophic 

(pylorus).*  gastritis  (alcoholic).* 

In  i^ractical  work,  the  following  clinical  forms  of  gastritis 
should   be  differentiated: 

1.  Acid  and  hyperacid  gastritis  (acid  catarrh  of  stomach). 

2.  Subacid  gastritis. 

3.  Anacid  gastritis. 

a.  Catarrhal,  or  simple  gastritis. 
6.  Interstitial  gastritis. 
c.  Atrophic  gastritis. 

4.  Stenotic  gastritis  or  cirrhosis  pylori. 

*  Specimens  furnished  through  the  courtesy  of  Dr.  Ethel  L.  Leonard,  Los 
Angeles,  Cal. 


DISEASES  OF  THE  STOMACH  81) 

The  old  view  that  stasis  of  the  stomach-contents  fre- 
quently occurs  in 'chronic  gastritis,  is  an  error.  On  the  con- 
trary, the  motihty  of  the  stomach  in  gastritis  rather  exceeds 
the  normal,  i.e.,  the  stomach  propels  the  food  into  the  intes- 
tine as  soon  after  eating,  or  perhaps  sooner,  for  the  reason 
that  normally  the  stomach  must  propel  the  food  as  well  as  its 
own  secretions. 

Stasis  occurs  only  in  stenotic  gastritis;  this  form  is  ex- 
ceedingly rare. 

In  gastritis,  therefore,  the  secretory  rather  than  the 
motor  functions  are  impaired. 

Fig.  23. 
120   »I20 
Hyperacid  G^sfrihs  ascending  /       \  Hyperacid  Dgstritis  descending 
80/  XsO 


—  Evolution  of  Gastritis 

in  Gourmonds 

—  Evolution  of  Gastritis 
in  Women  and  Alcoljolics. 


Diagram  showing  the  development  of  the  various  forms  of  chronic  gastritis. 

The  general  nutrition  of  the  patient  suffers  only  when  the 
appetite  is  lost,  the  motihty  disturbed  b}^  some  complication, 
or  the  functions  of  the  intestine  become  secondarily  involved. 

Etiology. — Chronic  gastric  catarrh  arises,  primarily,  from 
the  direct  effects  of  injuries  to  the  mucous  membrane  of  the 
stomach;  or,  secondarily,  as  a  complication  of  other  diseases 
of  the  stomach  or  other  organs  of  the  body. 

1.  Primary  chronic  gastritis  is  produced 
from  excesses  in  eating,  drinking,  and  smoking;  from  the 
misuse  of  laxatives,  especially  of  salines,  such  as  Carlsbad 
salts;  from  continued  improper  mastication  of  food,  irregular 
and  hasty  eating,  or  defective  teeth;   from  insufficient  nourish- 


90  DISEASES  OF  THE  DIGESTIVE  CANAL 

mcnt,— as  for  instance,  in  persons  who  live  on  bread  and 
coffe(>  only  and  who  eat  no  meat,  year  after  3'car. 

The  misuse  of  alcohol  and  tobacco  is  especially  important 
in  men,  and  in  women  the  other  causes  in  question. 

According  to  Martins,  a  congenital  insufficiency  of  the 
gastric  glands  is  possible. 

There  are  frequently  cases  in  which  the  etiolog}'  of  the  disease  cannot 
be  established.  Whenever  possible,  the  causative  factors  should  be  care- 
fully traced  and  the  treatment  directed  toward  their  removal. 

Excesses  in  smoking,  meat-eating,  and  wine-drinking 
are  generally  the  cause  of  hyperacid  catarrh  of  the  stomach, — 
the  so-called  ''acid  gastritis;"  while  the  misuse  of  whisky 
produces  a  subacid  or  anacid  gastritis, — a  clinical  fact  which 
has  recently  been  experimentally  established  by  Kast.* 

Acid  gastritis  occurs,  therefore,  most  frequently  in  obese 
men,  and  scarcely  ever  in  women. 

Chronic  gastritis,  like  acute  catarrh  of  the  stomach,  may 
also  be  caused  by  occupation  poisons  and  by  the  use  of  irrita- 
tive drugs,  such  as  salicylic  acid,  vermifuges,  etc. 

2.  Second  ar  5^  chronic  gastritis  may 
appear  as  a  complication  of  carcinoma  of  the  stomach  itself, 
or  in  the  course  of  cancer  of  other  organs  of  the  body, — for 
instance,  the  uterus,  lungs,  or  intestines, — as  soon  as  general 
cachexia  has  developed.  On  the  same  principle,  atrophic 
gastritis  develops  almost  without  exception  in  patients  suf- 
fering from  progressive  pernicious  anaemia. 

I  cannot  agree  with  those  authors  who  consider  that  atrophy  of  the 
gastric  glands  is  the  cause  and  not  the  result  of  the  pernicious  anaemia. 

Milder  secondary  gastric  catarrhs  are  caused  by  passive 
congestion  in  either  the  greater,  the  lesser,  or  the  portal 
circulatory  systems;  for  instance,  in  chronic  diseases  of  the 
heart,  lungs,  liver,  and  kidneys.  These  are  usually  of  the 
anacid   form   of   gastritis. 

Secondary  acid  gastritis,  or  gastritis  hyperpeptica,  oc- 
curs in  ulcer  or  stenosis  of  the  pylorus,  in  which  event  the 

*Arch.  f.  Verdauungskr.,  Bd.  12,  p.  487. 


DISEASES  OF  THE  STOMACH  91 

irritation  of  the  gastric  mucosa  has  been  caused  by  the  stag- 
nating food-contents  of  the  stomach. 

Symptomatology. — As  in  every  other  disease  of  the 
alimentary  tract,  there  are  present  both  general  and  local 
subjective  symptoms,  and  both  general  and  local 
objective     findings. 

1.  The  general  subjective  symptoms  are 
lassitude,  disinclination  to  work,  and  frequently  loss  of  appe- 
tite or  perversion  of  taste. 

The  local  subjective  sj^mptom  is  pressure  in 
the  stomach,  especially  after  eating  solids, — which  is  a  general 
symptom  of  all  forms  of  gastritis.  After  the  patient  has  taken 
soups  or  other  liquids,  except  cold  drinks,  this  pressure  does 
not  occur. 

Pressure  in  the  stomach  is  characteristic  of  gastritis, 
especially  if  it  occur  after  the  patient  has  eaten  such  foods 
as  beef,  hard  bread,  cabbage,  cheese,  hard-boiled  eggs,  fried 
potatoes,  meats,  etc. 

Actual  pain,  as  well  as  vomiting,  rarely  occurs  in  chronic 
acid  gastritis.  In  advanced  forms  of  atrophic  gastritis,  gnaw- 
ing pains  and  vomiting  usually  occur  several  hours  after 
indiscretions  in  diet. 

In  stenotic  gastritis  caused  by  hypertrophic  stenosis  of 
the  pylorus,  vomiting  and  pain  set  in  regularly  after  errors 
in  diet.    Food-stasis  occurs  exclusively  in  this  form  of  gastritis. 

Pyrosis,  so-called  ''heart-burn,"  occurs  in  hyperacid 
gastritis. 

2.  The  general  objective  findings  are :  In- 
dividuals suffering  from  chronic  gastritis  may  be  well  or  badly 
nourished,  according  to  the  amount  of  food  they  are  able  to 
take,  which  is  in  turn  dependent  upon  the  appetite,  and  upon 
whether  they  suffer  much  or  little  after  eating.  It  has  already 
been  mentioned  that  nutrition  does  not  suffer  from  deficient 
gastric  digestion  alone,  but  rather  from  a  diminution  in  the 
amount  of  food  which  enters  the  body. 

The  majority  of  patients  suffering  from  chronic  gastritis 
are   aneemic,   under-nourished,   and   have   the   appearance   of 


92  DISEASES  OF  THE  DIGESTIVE  CANAL 

being  ill,  although  there  arc  quite  a  large  number  of  patients 
suffering  from  ehronic  gastritis  that  are  well  nourished. 

The  administration  of  the  test-supper  (see  Special  Sec- 
tion) will  show  that  the  motility  of  the  stomach  in  gastritis 
is  quite  normal.  The  examination  of  the  test-breakfast  always 
shows  characteristic  deviations  from  the  normal. 

In  hyperacid  gastritis,  the  total  acidity  is  increased,  on  the 
average,  to  80,  but  in  some  cases  it  may  reach  to  as  high  as  120. 

The  diagnosis  of  gastritis  may  be  established  if  the  patient 
gives  the  characteristic  symptoms  and  etiology  of  the  disease, 
even  when  the  total  acidity  is  normal,  i.e.,  T.A.  40  to  60 
(gastritis  acida  orthochlorica) . 

In  subacid  gastritis,  the  total  acidity  amounts  to  less  than 
40.  Free  hydrochloric  acid  is  still  present,  however,  as  will 
be  shown  by  the  blue  reaction  of  red  congo  paper.  The  test- 
breakfast  shows  that  the  chymification  of  food  is  but  little 
reduced.  In  this  form  of  gastritis,  the  diagnosis  is  estabhshed 
only  by  the  general  ensemble  of  sj^mptoms. 

In  acid  gastritis,  free  hydrochloric  acid  is  entirely  absent, 
Congo  paper  is  not  colored  blue,  and  the  total  acidity  amounts 
to  20  or  less.  The  production  of  ferments  is  diminished  or 
entirely  absent,  as  has  been  explained  in  the  General  Section. 

All  references  to  the  total  acidity  of  the  gastric  juice  apply  to  the 
Boas-Ewald  test-breakfast,  which  consists  of  60  to  65  grams  of  dry  white 
bread  and  400  c.c.  of  water.  Since  white  bread  ahvays  contains  practically 
the  same  proportion  of  albumen,  the  amount  representing  the  total  acidity 
in  which  free  hydi-ochloric  acid  is  present  must  always  be  approximately 
the  same.  In  general,  it  may  be  said  that  free  hydrochloric  acid  is  secreted 
when  the  total  acidity  of  the  gastric  juice  amounts  to  20  or  more. 

Atrophic  gastritis  exists  when  there  is  permanent  cessa- 
tion of  the  secretion  of  gastric  juice.  The  total  acidity  amounts 
to  from  5  to  8;  in  interstitial  gastritis,  from  10  to  16.  In 
simple  catarrhal  gastritis,  the  total  acidity  amounts  to  from 
16  up  to  the  occurrence  of  the  secretion  of  free  hydrochloric 
acid.  The  diminished  secretion  of  gastric  juice  in  atrophic 
gastritis  is  accompanied  by  a  corresponding  decrease  in  the 
amount  of  rennin  and  pepsin.     (See  General  Section.) 


DISEASES  OF  THE  STOMACH  93 

The  less  the  test-breakfast  is  mixed  with  the  gastric 
secretions,  the  less  digested  is  its  appearance.  If  there  is  total 
absence  of  gastric  juice,  the  test-meal  has  the  appearance  of 
having  been  chewed  and  immediately  eructated.  This  con- 
dition has  been  designated  by  Einhorn,  "  achylia  gastrica." 

The  amount  of  mucus  in  the  stomach-contents  is  sub- 
ordinate to  other  signs,  in  making  the  diagnosis,  for  the  reason 
that  a  pharyngitis  almost  always  exists  simultaneously. 

The  appearance  of  the  tongue  in  chronic  gastritis  is 
entirely  dependent  upon  the  appetite,  which,  in  some  cases, 
is  very  good.  The  less  the  patient  masticates  his  food,  the  more 
the  tongue  will  be  coated,  because  the  latter  does  not  receive 
the  mechanical  cleansing  which  results   from   mastication. 

The  vomiting  of  mucus  early  in  the  morning,  so-called 
vomitus  matutinus,  occurs  very  frequently,  as  is  well  known, 
in  alcoholic  gastritis.  Boas  has  shown,  however,  that  this 
depends  upon  co-existing  pharyngitis  and  oesophagitis;  the 
large  amount  of  mucus  produced  by  catarrh  of  the  pharynx, 
and  the  sputum,  pass  into  the  oesophagus  during  the  sleep 
of  the  patient,  and  cause  him  to  awaken  early  in  the  morning 
with  tickling  and  irritation  of  the  throat,  spells  of  nausea,  and 
usually  vomiting  of  the  swallowed  mucus. 

Only  in  rare  cases  does  the  mucus  in  the  matutinal  vomit- 
ing have  its  origin  in  the  stomach  itself. 

Another  objective  symptom  is  sensitiveness  to  pressure 
in  the  epigastrium.  This  is  never  so  localized  and  intense  as 
in  ulcer  of  the  stomach,  but  is  more  diffuse.  Pyrosis,  which 
occurs  in  hyperacid  gastritis,  will  be  spoken  of  below. 

Prognosis  and  Course. — The  prognosis  of  chronic  gas- 
tritis, so  far  as  life  is  concerned,  is  very  good,  while  the  chances 
for  complete  recovery  are  poor.  Most  cases  are  clinically 
cured;  that  is  to  say,  by  adhering  to  a  rational  diet,  such 
patients  are  freed  from  suffering  and  enjoy  good  health. 
The  physician,  however,  is  never  able  to  guarantee  the  patient 
exemption  from  relapse,  should  errors  in  diet  be  made,  for  a 
sufferer  with  chronic  gastritis  must,  in  a  measure,  during  his 
entire  life,  "cut  the  garment  according  to  the  cloth." 


94  DISEASES  OF  THE  DIGESTIVE  CANAL 

Complete  restoration  can  result  only  if  treatment  is 
sought  during  the  initial  stages  of  the  disease,  i.e.,  in  hyper- 
acid gastritis,  subacid  gastritis,  or  catarrhal  gastritis,  in  which 
forms  few  or  no  interstitial  alterations  of  the  mucosa  of  the 
stomach  have  occurred. 

Chronic  gastritis  may  exist  for  years  without  symptoms, 
which  will  then  appear  gradually.  Later  in  the  disease,  the 
intestine  may  become  involved  from  the  irritation  to  which 
it  has  been  for  a  number  of  years  subjected  by  the  introduc- 
tion of  undigested   food. 

In  other  cases,  the  same  etiological  factors, — such  as,  for 
instance,  the  abuse  of  alcoholic  stimulants  and  overeating, — 
may  simultaneously  produce  an  inflammation  of  the  stomach 
and  of  the  intestine.  It  is  for  this  reason  that  a  large  number 
of  patients  suffer  from  gastritis  and  chronic  diarrhoea  at  the 
same  time;  while  in  other  cases,  intestinal  symptoms  precede 
stomach-indigestion. 

It  should,  therefore,  be  emphasized  here  that  examina- 
tion of  the  stomach-contents  is  absolutely  essential  in  all 
cases  where  patients  suffer  from  chronic  diarrhoea,  although 
they  may  not  complain  of  trouble  in  the  stomach  after  eating. 

The  nutrition  in  gastritis  suffers  very  considerably  when 
it  is  associated  with  diarrhcea,  otherwise  these  patients  are 
well  nourished  until  there  is  a  diminution  of  the  appetite. 

.The  prognosis  of  chronic  gastritis  is,  therefore,  dependent 
upon  whether  the  patient  is  able  to  bring  about  a  change  in 
his  usual  customs  and  habits;  whether  he  continues  to  smoke 
and  drink;  whether  he  persists  in  hasty  and  irregular  eating; 
and  whether,  if  poor,  he  has  the  advantages  of  a  suitable 
dietary  and  sufficient  rest. 

Hyperacid  gastritis  gradually  progresses  into  the  sub- 
acid and  anacid  forms  of  the  disease,  if  the  causa  morhi 
remains  active. 

Diagnosis. — The  diagnosis  of  chronic  gastritis  is  usually 
easy  if  the  physician,  in  addition  to  the  anamnesis  and  the 
physical  examination,  gives  the  test-meal.  Diagnosis  should 
be  formed  from  the  complaints  of  the  patient  and  the  findings 


DISEASES  OF  THE  STOMACH  95 

of  the  examination,  but  never  from  either  of  these  alone, 
if  the  examiner  would  avoid  being  frequently  led  into  error. 

The  most  important  subjective  symptom  is  pressure 
which  occurs  after  eating  soHds.  Objectively,  the  most  im- 
portant diagnostic  sign  is  a  pathological  alteration  in  the 
secretions  of  the  stomach.  Besides  these,  an  etiological  factor 
must  be  ascertained  by  the  anamnesis. 

Differential  Diagnosis. — Gastric  neuroses  and  functional 
dyspepsia  are  the  most  frequent  stomach-affections  to  be 
differentiated  from  gastritis. 

In  these  affections,  the  general  statement  may  be  made, 
that  pressure  occurs  after  eating  any  kind  of  food, — after 
liquids  as  well  as  solids, — and  that  the  gastric  secretions  are 
normal,  or  else  variable  from  day  to  day. 

Besides  this,  gastric  neuroses  occur  principally  in  persons 
with  habitus  enter ovticus,  while  gastritis  is  found  usually  in 
persons  with  normal  habitus  (see  above). 

Hence  the  differential  diagnosis  is  difficult  only  when, 
on  account  of  nervous  influences,  the  secretion  of  hydro- 
chloric acid  is  also  diminished. 

The  physician  will  be  assisted  in  estabhshing  an  exact 
diagnosis  by  an  accurate  examination  of  the  gastric  fer- 
ments,— rennin  and  pepsin, — which,  in  neuroses,  should  be 
found  present  in  normal  amounts;  and  also  by  a  consideration 
of  the  general  condition  and  symptoms  of  the  patient. 

Gastritis  is,  as  a  rule,  easily  differentiated  from  ulcer  of 
the  stomach,  because  in  ulcer  the  patient  suffers  from  epi- 
gastralgia  rather  than  from  pressure.  This  epigastralgia  sets 
in,  as  a  rule,  one  or  two  hours  after  the  principal  meal,  and  the 
acidity  of  the  gastric  juice  is  almost  always  increased. 

The  differentiation  will  be  difficult  only  wdien  there  are 
erosions  or  fissures  of  the  pylorus  in  hyperacid  gastritis.  In 
such  cases,  Hkewise,  burning  or  gnawing  pains  occur  in  the 
epigastrium  some  time  after  eating.  In  these  cases,  the 
physician  is  no  longer  concerned  with  pure  gastritis,  but  with 
the  combination  of  erosions  or  ulcer  with  gastritis.  In  general 
this  is  rare,  and  occurs  only  in  patients  who  smoke  to  excess. 


96  DISEASES  OF  THE  DIGESTIVE  CANAL 

Gastritis  is  very  easily  differentiated  from  dilatation  of 
the  stomach,  because  in  gastritis  no  stagnation  of  food  occurs. 
Only  in  stenotic  gastritis  (cirrhosis  pylori)  does  one  find  a 
combination  of  ectasia  and  chronic  gastritis.  The  inflam- 
matory process  produces,  in  these  cases,  a  hjq^ertrophic 
stenosis  of  the  pylorus,  with  secondary  motor  insufficiency 
and  dilatation  of  the  stomach. 

It  is  seldom  possible  to  differentiate  gastritis  from  the 
initial  stage  of  carcinoma.  If  the  cancer  is  not  located  at 
the  pjdorus  or  at  the  cardia,  no  obstructive  symptoms  are 
present;  and  if  no  tumor  is  palpable,  the  physician  will  find 
objectively  nothing  more  than  the  same  evidences  of  achylia 
gastrica  as  occur  in  benign  atrophy  of  the  mucous  membrane. 

The  subjective  symptoms  of  the  initial  stage  of  carcinoma 
are  also  the  same  as  the  subjective  symptoms  of  gastritis. 
Only  by  a  microscopical  examination  of  the  stomach-contents, 
obtained  several  hours  after  eating,  may  the  diagnostic  points 
be  learned  for  the  differentiation  of  these  doubtful  cases. 
The  presence  of  many  pus-  and  blood-corpuscles  in  the 
stomach-contents  is  an  evidence  of  cancer. 

The  failure  of  the  Rhodankalium  reaction  in  the  saliva 
(appearance  of  a  red  color  after  adding  one  drop  of  ferric  chlo- 
ride), according  to  Schmidt,  of  Vienna,  is  an  evidence  of  cancer. 

The  many  varieties  of  gastritis  are,  as  a  rule,  easily  dif- 
ferentiated by  the  examination  of  the  gastric  juice  and  by 
making  the  ferment-tests  (see  page  29). 

Treatment. — The  treatment  of  chronic  gastritis  is:  (1) 
hygienic;  (2)  dietetic;  (3)  medicinal;  (4)  mechanical;  and 
(5)  balneological. 

1.  Hygienic. — In  alcoholic  gastritis  (hyperacid  and  anacid 
forms),  drinking  and  smoking  are  to  be  especially  limited, 
or,  if  possible,  entirely  prohibited  for  a  long  time. 

When  gastritis  has  originated  from  insufficient  mastica- 
tion, in  consequence  of  defective  teeth,  the  patient  should  be 
referred  to  a  dentist.  The  great  value  of  eating  leisurely, 
and  the  disadvantages  of  hasty  eating,  are  to  be  strongly 
impressed  upon  the  patient. 


DISEASES  OF  THE  STOMACH  97 

Compression  of  the  epigastric  region  }3y  tight  clothing 
must  also  be  condemned. 

If  the  disease  is  attributable  to  the  misuse  of  saline  lax- 
atives, evacuation  of  the  bowels  should  be  obtained  by  sub- 
stituting dietetic  and  mechanical  measures. 

2.  Dietetic. — The  dietetic  treatment  is  similar  in  all 
forms  of  chronic  gastritis.  A  few  exceptions,  which  will 
be  separately  considered,  are  to  be  observed  in  acid  gastritis. 
The  dietetic  treatment  of  gastritis  is  dependent  upon  the 
principle  that  the  inflamed  mucous  surfaces  should  be  spared 
as  much  as  possible,  and  that  the  diet  must  be  adapted  to  the 
altered  functions  of  the  gastric  mucous  membrane.  Soft, 
pulpy  foods,  therefore,  must  predominate  in  the  diet,  while 
solids  should  be  largely  eliminated. 

A.  Diet  in  Subacid  and  Anacid  Gastritis. — The  follow- 
ing foods  should  be  forbidden:  hard  bread,  pumpernickel, 
and  hardtack;  coarse  vegetables,  like  cabbage  and  fried 
potatoes;  raw  fruit,  stewed  acid  fruits,  such  as  currants  or 
gooseberries,  and  fruits  containing  seeds;  legumes  and  nuts, 
of  milk  products,  hard  cheese  and  sour  milk;  of  meats,  bacon, 
goose,  duck,  fat  ham,  mutton  and  pork;  smoked  fish,  such  as 
red  herring  and  salmon;  also  hard-boiled  eggs,  ma3^onnaise, 
and  all  forms  of  fat  except  butter. 

The  following  foods  are  allowed: 

a.  Soups  in  every  form  and  consistency,  beef  tea,  with  the 
addition  of  eggs,  cereals,  noodles,  macaroni,  and  soft  vege- 
tables;   oatmeal,  flour,  milk,  and  bread  soups,  etc. 

6.  Rice,  sago,  millet,  tapioca,  oatmeal, — cooked  in  broth 
or  milk;  puree  of  potato,  Brussels  sprouts,  spinach,  carrots, 
green  peas,  asparagus,  and  cauhflower;  fruit  gelatins  and 
sweet  stewed  fruit,  such  as  apple  sauce,  plum  sauce,  straw- 
berries  and  raspberries. 

c.  White  bread,  toasted  white  bread,  zwieback,  "Force," 
and  in  mild  cases,  small  amounts  of  English  white  bread. 

d.  Milk,  cream,  and  butter. 

e.  Chicken  and  pigeon, — boiled  or  broiled  in  butter; 
veal, — boiled  or  broiled  medium  rare;  calves'  brain  and  sweet- 

7 


98  DISEASES  OF  THE  DIGESTIVE  CANAL 

breads;  beef  and  ham  free  from  fat,  which  may  be  roasted 
or  grilled. 

In  severe  cases,  such  as  atrophic  gastritis,  only  the 
most  tender  meats  and  lean  fish,  such  as  pike,  perch,  flounder, 
and  shell-fish;  roe,  pheasant,  partridge;  but  never  hare, 
deer,  nor  any  smoked  game. 

/.  The  following  relishes  and  beverages  are  allowed: 
tea,  small  amounts  of  cofTee,  diluted  wine,  mineral  water, 
with  or  without  the  addition  of  fruit  juices;  cocoa,  chocolate, 
caviare,  sardines,  and  spices. 

g.  Artificial  foods:  puro,  sanatogen,  somatose,  meat  jellies, 
meat  juices,  and  calves'-foot  jelly. 

In  the  treatment  of  chronic  gastritis,  the  condition  of  the 
bowels  and  the  general  health  of  the  patient  must  be  carefully 
taken  into  account.  For  instance,  if  constipation  exists  purees 
of  fruits  and  vegetables,  fruit  juices  and  koumiss  are  to  be  pre- 
scribed. On  the  other  hand,  if  diarrhoea  or  a  tendency  toward 
diarrhoea  is  present,  all  foods  that  stimulate  peristalsis  should 
be  avoided  and  only  those  prescribed  that  have  an  astringent 
effect, — such  as  cocoa,  red  wine,  huckleberry  wine,  etc. 

Very  frequently,  in  gastritis,  it  is  necessary  to  combine 
the  gastritis  and  the  diarrhoea  dietaries;  or  the  gastritis- 
constipation  and  the  gastritis-fattening  dietaries.  (Special 
diet-lists  will  be  found  in  the  Dietetic  Outlines.) 

B.  Diet  in  Hyperacid  Gastritis. — The  diet  in  this  form 
of  gastric  catarrh  differs  from  the  diet  in  chronic  gastritis, 
in  that  all  fats  and  spices,  and  other  strongly  irritating  foods, 
as  well  as  strong  coffee,  tobacco,  and  cold  drinks, — such  as 
beer,  champagne,  and  white  wine, — must  be  absolutely  for- 
bidden. Sweetmeats  and  rich  dinners,  especially  for  patients 
who  have  thus  brought  about  acid  gastric  catarrh,  should  be 
avoided.  Warm  drinks  are  to  be  recommended,  such  as  hot 
milk,  warm  Vichy  water,  etc.,  to  relieve  the  burning  pains  and 
pyrosis  of  the  stomach. 

From  the  practical  standpoint,  the  remaining  thera- 
peutic procedures  in  the  different  forms  of  gastritis  should  be 
sepaTately  considered: 


DISEASES  OF  THE  STOMACH  99 

I.     Hyperacid  Gastritis 

(Acid  Catarrh  of  the  Stomach.     Gastrite  Hyperpeptique.) 

3.  Medicinal  Treatment. — 

a.  Belladonna  preparations  are  prescribed  for  the  sup- 
pression of  hypersecretion. 

b.  Bitters  are  used  for  the  stimulation  of  the  appetite. 

c.  Antacids  should  be  symptomatically  given  after  eating, 
to  neutralize  the  acidity  of  the  gastric  juice. 

Belladonna  is  to  be  given  in  the  form  of  the  extract,  the 
tincture,  or  as  atropine  in  solution  or  tablets. 

Of  the  bitters,  condurango  bark  is  the  most  effective; 
either  a  teaspoonful  of  the  decoction  or  of  the  fluid  extract 
should  be  given  before  meals.  Other  bitters  are  the  tinctures 
of  rhubarb  or  gentian,  the  compound  tincture  of  cinchona, 
the  fluid  extract  of  calamus,  or  bitter  almond  water,  which 
may  be  given  before  meals,  in  doses  of  one-half  to  one  tea- 
spoonful.     Resorcinol  and  creosote  are  also  recommended. 

The  antacids  should  be  prescribed  according  to  the  fol- 
lowing principles: 

1.  If  the  bowels  are  normal,  sodium  salts,  sodium  citrate, 
bi-carbonate  or  phosphate  should  be  given. 

2.  If  constipation  exists,  magnesium  salts, — calcined 
magnesium  or  magnesium-ammonium  phosphate, — should  be 
prescribed. 

3.  In  diarrhoea,  the  salts  of  calcium, — calcium  carbonate 
and  calcium  phosphate, — should  be  used. 

As  a  rule,  the  following  prescriptions  are  all  I  have 
needed: 

1.  I^    Tincturse  belladonnae  foliorum,  ttl  Ixxx-oiiss        5.0-10.0 

Tincturae  gentianas, 

(or  calami,  rhei,  or  cinchonae),  oi  30.0 

M.    Sig. — 30  to  40  drops,  5  to  15  minutes  before  meals  on  sugar 
or  in  a  wineglassful  of  water. 

2.  I^     Extracti  beUadonnse  foliorum,  gr.  iii-ivss        0.2-0.3 

Sodii  bicarbonatis, 

Magnesii  oxidi,  aa,  3v  20.0 

M.ft.pulv.  Sig. — One  teaspoonful  2  or  3  times  daily,  1  to  3 
hours  after  meals  for  cramp-like  or  burning  pains  in  the 
epigastrium. 


100  DISEASES  OF  THE  DIGESTIVE  CANAL 

3.  I^     Extracti  condurango  fluidi,  oiss  50.0 
-  Sig. — One  teaspoonful  t.i.d.,  5  to  15  minutes 

before  eating,  for  loss  of  appetite. 

4.  I^     Solution  argenti  nitratis — gr.  viiss  :  oviss     0.5  :  200.0 
Sig. — One  tablespoonful  (porcelain)  in  a  wineglassful  of 

distilled  water  15  minutes  before  eating,  for  pyrosis. 

In  acid  gastritis,  if,  besides  the  usual  pressure,  there  also 
occur  burning  pains  in  the  epigastrium  two  or  three  hours 
after  a  heavy  meal,  the  physician  must  always  think  of  the 
possible  complication  of  erosion  and  catarrh.  If  the  pains 
are  of  a  crampy  nature,  the  erosion  is  most  probably  located 
at  the  pylorus.  In  such  cases,  the  physician  should  prescribe 
belladonna  combined  with  an  alkali.     (See  above.) 

In  addition  to  these  remedies,  the  following  medica- 
ments are  very  useful: 

1.  I^     Bergmann's  or  Belloc's  mastication  tablets. 
Sig. — One  to  tliree  tablets  after  meals. 

2.  J^     Extracti  belladonnse  foliorum,  gr.  iiss       0.15 

Bismuthi  subnitratis,  5iv  15.0 

M.    Sig. — One  knifepointful  three  times  daily  after  meals. 

These  "mastication  tablets"  should  be  chewed  as  thor- 
oughly as  possible  and  dissolved  in  the  mouth;  this  will 
cause  the  patient  to  swallow  a  large  amount  of  sahva,  which 
will  tend  to  iieutraHze  the  hyperacid  gastric  juice. 

The  Bergmann  tablets  are  effective  almost  entirely 
through  this  mechanical  effect  of  stimulating  the  secretion 
of  saliva;  while  the  Belloc  tablets  contain  belladonna,  char- 
coal, and  magnesia. 

The  chewing  of  hard  bread-crusts,  or  taking  a  hot  drink 
about  an  hour  after  meals,  relieves  the  pain  by  introducing 
an  increased  amount  of  sahva  into  the  stomach  and  by  dilut- 
ing the  gastric  juice. 

Medicaments  for  the  relief  of  pain  should  always  be 
given  about  one-half  hour  before  the  attack  usually  occurs. 

4.  Mechanical  Treatment. — In  acid  gastritis,  lavage  is 
usually  superfluous,  unless  stagnation  of  the  stomach-con- 
tents occurs  as  a  complication. 


DISEASES  OF  THE  STOMACH  101 

It  must  be  said,  however,  that  irrigation  of  the  gastric 
mucous  membrane  with  a  1  to  1000  solution  of  silver  nitrate 
is  decidedly  beneficial  in  cases  of  acid  gastritis  complicated 
with  erosions.  Irrigations  with  a  solution  of  sodium  bicar- 
bonate or  Carlsbad  salts  are  also  recommended. 

Bourget  has  recently  advised  lavage  with  a  one  per  cent, 
solution  of  liquor  ferri  chloridi  in  stubborn  cases  of  acid  gas- 
tritis. One  hundred  c.c.  of  this  solution  are  introduced  and 
afterwards  washed  out  with  warm  water. 

The  idea  that  the  mucous  membrane  must  be  cleansed 
of  its  adherent  mucus  in  every  case  of  chronic  gastritis  is 
now  obsolete. 

The  use  of  hot  mud-poultices  or  Priessnitz  compresses 
is  recommended  if  erosions  of  the  mucosa  are  suspected. 

5.  Balneological  Treatment. — The  physician  should  pre- 
scribe Carlsbad  or  Neuenahr  water  for  patients  who  are  strong 
and  rugged,  and  Vichy  for  those  who  are  delicate.  These 
waters  should  always  be  taken  hot,  about  35°  to  40°  R.  [110°- 
112°  F.]  The  direct  use  of  the  water  at  the  springs  is  most 
effective.  As  home  treatment,  these  mineral  waters  may  be 
given  at  the  same  temperature;  while  with  patients  of  the 
poorer  classes,  it  is  advisable  to  prescribe  either  the  natural 
spring-water  salts  or  the  artificially  prepared  salts  dissolved 
in  water.  Three  or  four  glasses,  each  containing  200  c.c.  of 
water,  should  be  given  daily  before  meals, — one  or  two  glasses 
early  in  the  morning  before  breakfast,  one  glass  at  mid-day 
and  one  in  the  evening.  This  treatment  should  continue  six 
or  eight  weeks. 

n.    Subacid  and  Anacid  Gastritis 

The  (1)  hygienic  and  (2)  dietetic  treatment  has  already 
been  considered,  and  for  the  suitable  dietary  the  reader  is 
referred  to  the  Dietetic  outlines. 

3.  Medicinal  Treatment. — In  these  forms  of  gastritis, 
actual  pain  almost  never  occurs,  except  after  gross  errors  in 
diet.  Narcotics  and  antacids  are  therefore  not  required, 
because  hyperacidity  does  not  exist. 


102  DISEASES  OF  THE  DIGESTIVE  CANAL 

On  the  other  hand,  bitters  (see  above)  are  more  freely 
prescribed;  for  the  reason  that  tho  appetite  in  these  cases  is 
generally  much  decreased. 

As  a  rule,  the  use  of  hydrochloric  acid,  either  alone  or 
in  combination  with  a  bitter,  should  be  in  amounts  propor- 
tionate to  the  atrophic  process  of  the  mucous  membrane  of 
the  stomach. 

The  following  prescriptions  are  suitable: 

1.  Acidi  hydrochlorici  off.,     oi     30,0 
Sig. — Eight  to  ten  drops  in  a  wineglassful  of  water  three  times  daily  im- 
mediately after  meals.     (In  severe  cases,  repeat  the  dose  in  half  an  hour;  and  in 
total  atrophy  with  enterocolitis,  repeat  the  dose  a  third  time.) 

2.  I^     Acidi  hydroclilorici  diluti,  ,5ss  2.0 

Tinctura;  gentiana?  (rhei,  etc.),  oi      30.0 
Sig. — One-half  teaspoonful  three  times  daily. 

3.  R     All  Bitters. 

Sig. — One-half  to  one  teaspoonful  tliree  times 
daily  before  meals. 

In  general  practice,  the  following  remedies  are  especially 
valuable  in  atrophic  gastritis:  Pepsin,  papain  in  tablets  of 
0.3  to  0.5  [5  to  8  gr.],  or  pancreatin  in  knifepoint  doses.  Re- 
cently the  use  of  pancreon  in  tablets  of  one-half  gram,  or  as 
a  powder  combined  with  sodium  bicarbonate  in  knifepoint 
doses,  has  been  found  beneficial. 

Pepsin  should  be  administered  in  combination  with 
hydrochloric  acid,  because  it  is  active  only  in  an  acid  medium. 
The  other  preparations  should  be  administered  without  hydro- 
chloric acid,  because  of  the  well-known  fact  that,  with  the 
exception  of  papain,  they  are  able  to  digest  albumin  only  in 
an  alkaline  medium. 

In  the  medical  treatment,  the  examiner  must  very  fre- 
quently take  into  consideration  the  condition  of  the  intestine, 
because  there  is  often  a  co-existing  intestinal  catarrh  with 
diarrhoea  or,  more  rarely,  with  constipation.  For  a  detailed 
consideration  of  this  subject,  the  reader  is  referred  to  the 
section  on  Enterocolitis. 


DISEASES  OF  THE  STOMACH  103 

4.  Mechanical  Treatment. — Lavage  and  irrigation  of  the 
mucous  membrane  of  the  stomach  with  normal  alkahne  solu- 
tion is  beneficial,  but  not  absolutely  necessary.  A  positive 
indication  for  lavage  does  not  exist.  Neither  can  favorable 
results  be  expected  from  electrical  treatment,  for  the  reason 
that  motility  in  this  form  of  gastritis  is  nearly  always  normal. 

5.  Balneological  Treatment. — The  sodium  chloride  mineral 
water  of  the  Rakoczy  spring  at  Kissingen,  the  Kochbrunnen 
of  Weisbaden,  and  the  EHzabeth  spring  at  Homburg,  as  well 
as  those  at  Baden  Baden,  Ems,  etc.  [Champion,  Congress, 
and  Hawthorn  springs  at  Saratoga,  N.  Y.,  or  Blue  Lick 
springs,  Ky.],  are  indicated  in  subacid  or  anacid  gastritis. 
Whenever  possible,  the  patient  should  be  sent  to  one  of  these 
places  to  follow  out  the  treatment,  or,  if  necessary,  he  may 
drink  the  bottled  waters  at  home.  Patients  who  are  in  limited 
circumstances  may,  however,  be  given  the  artificially  pre- 
pared salts,  dissolved  in  warm  water. 

If  this  form  of  gastritis  is  associated  with  constipation, 
the  water  should  be  drunk  slightly  warmed.  If  there  is  a  tend- 
ency toward  diarrhoea,  on  the  other  hand,  it  should  be  drunk 
as  hot  as  possible,  and  in  smaller  doses. 

III.     stenotic  Gastritis 

This  form  of  gastritis  is  exceedingly  rare.  It  is  caused 
by  hypertrophy  of  the  musculature  of  the  pyloric  end  of  the 
stomach,  as  a  compensatory  process  brought  about  by  the 
increased  demands  made  upon  the  organ  in  atrophic  gastritis; 
for  it  is  evident  that  more  muscular  power  is  demanded  of 
the  stomach  to  propel  foods  not  sufficiently  chymified  into 
the  duodenum  than  foods  which  are  well  digested  and  mixed 
with  an  abundance  of  gastric  juice. 

Hypertrophy  of  the  pars  pylorica  frequently  simulates 
the  symptoms  of  a  tumor  of  the  pylorus,  since  besides  the 
thickening  of  this  part  of  the  stomach,  there  is, — in  con- 
sequence of  the  hjqDertrophic  stenosis  of  the  pylorus, — 
stagnation  of  the  stomach-contents,  with  lactic-acid  fer- 
mentation. 


104  DISEASES  OF  THE  DIGESTIVE  CANAL 

In  these  cases,  only  by  a  long  observation  of  the  patient 
is  the  physician  able  to  differentiate  stenotic  gastritis  from 
cancer  of  the  pylorus.  (For  further  details  concerning  the 
differential  diagnosis,  the  reader  is  referred  to  the  chapter 
on  Microscopic  Examination  of  the  Gastric  Contents.) 

Treatment. — The  hj^gienic,  dietetic,  and  mechanical  treat- 
ments are  the  same  as  in  stenosis  of  the  pylorus. 
The  physician  is  referred,  therefore,  to  that  subject  for  the 
details  in  the  management  of  these  cases.  It  need  only  be 
mentioned  that  in  stenotic  gastritis,  a  total  atrophy  of  the 
gastric  glands  is  present.  Meats,  therefore,  should  be  pre- 
scribed in  the  form  of  purees  only.  This  precaution  is  not 
needed  in  the  other  forms  of  benign  stenosis  of  the  pylorus, 
for  the  reason  that  in  these  the  gastric  juice  is  secreted  in 
amounts  sufficient  to  peptonize  meat.  All  hard  or  coarse 
foods  and,  in  fact,  all  foods  not  of  a  liquid  or  semi-liquid  nature 
should  be  strictly  forbidden. 

Mechanical  and  Medicinal  Treatment. —  Olive  oil,  milk  of 
almonds,  hydrochloric  acid,  pepsin,  and  the  bitters  are  to  be 
prescribed  as  detailed  in  the  chapter  on  Treatment  of  Ulcer  of 
the  Stomach,  to  which  the  physician  is  referred. 

Balneological  therapy  is  contraindicated, 
since  this  form  of  treatment  would  cause  an  overtaxing  of 
an  already  dilated  stomach. 

In  general,  the  treatment  of  stenotic  gastritis  is  identical 
with  that  of  cancer  of  the  pylorus. 

In  severe  forms,  which  have  produced  a  high  degree  of 
stenosis,  the  physician  is  in  duty  bound  to  advise  operation 
(gastro-enterostomy ) . 

IV.     Secondary  Gastritis 

The  rational  treatment  of  secondary  gastritis  is  naturally 
that  of  the  primary  disease;  for  instance,  in  affections  of  the 
heart,  digitalis  should  be  used,  etc.,  etc. 

If  the  primary  disease  is  incurable,  the  physician  must 
treat  the  gastritis  symptomatically,  in  the  same  way  as  he  would 
treat  gastritis  of  any  other  form.     Especial  emphasis  should 


DISEASES  OF  THE  STOMACH  105 

be  given  to  the  great  Value  of  free  diuresis  and  regular  evacua- 
tion of  the  bowels  in  gastritis  produced  by  passive  congestion 
of  the  mucous  membrane.  Under  this  treatment,  the  gastric 
symptoms  very  frequently  disappear. 

In  the  following  I  will  add  the  historips  of  a  number  of 
clinical  cases,  which  will  illustrate  the  various  forms  of 
gastritis : 

CLINICAL    CASES 

1.  Acid  Gastritis 

Case  1. — F.  A.,  a  policeman,  25  years  old,  entered  the  clinic  November 
8,  1902.  For  four  months  he  had  suffered  from  severe  pyrosis,  most  marked 
an  hour  and  a  half  after  meals;  and  from  pressure  and  burning  in  the  epi- 
gastrium,, especially  after  eating  fatty  foods.  He  was  very  strong,  rugged, 
and  corpulent.  The  test-breakfast  showed  a  marked  increase  in  the  hydro- 
chloric acid  of  the  stomach, — the  total  acidity  being  114. 

Treatment. — The  patient  was  given  a  teaspoonful  of  Sprudel  salts, 
dissolved  in  a  glass  of  warm  water,  early  in  the  morning  before  breakfast, 
and  a  teaspoonful  of  the  following  prescription  twice  daily,  one  hour 
after  meals: 

I^     Extracti  belladonnBe  foliorum,  gr.  ivss       0.25 
Magnesii  oxidi, 
Sodii  bicarbonatis,  aa   oviss  25.0 

Smoking  and  drinking  were  forbidden.  Under  this  treatment  the 
symptoms  disappeared  entirely  in  ten  months,  when  the  total  acidity  was  70. 

Case  2. — Carl  V.,  a  laborer,  29  years  old,  entered  the  clinic  December 
31,  1902.  For  a  year  and  a  half  or  two  years,  the  patient  had  suffered  from 
pressure  in  the  stomach,  especially  after  drinking  beer  and  eating  coarse 
solids, — such  as  cabbage,  rye  bread,  potatoes,  etc.  Soft  foods  and  warm 
drinks,  on  the  contrary,  had  produced  no  discomfort.  Pressure  in  the 
stomach  was  so  great  at  times  that  the  patient  sought  relief  by  artificially 
produced  vomiting.  Appetite  was  good.  Stools  were  dry  and  hard.  The 
patient  gave  a  history  of  excessive  eating  and  drinking  (ten  to  twelve  steins 
daily),  and  smoking.  Physical  examination  negative.  Total  acidity  of  the 
test-breakfast,  108. 

Treatment. — This  consisted  in  the  administration  of  Carlsbad  salts, 
belladonna,  tincture  of  valerian,  and  a  mild  diet.  Ten  days  later  the  patient 
was  much  improved,  and  the  total  acidity  was  80.  After  one  month's  treat- 
ment, the  pressure  in  the  stomach  had  absolutely  disappeared.  In  pre- 
senting the  case  three  months  later,  the  patient  stated  that  he  was  entirely 
free  from  gastric  discomforts. 


106  DISEASES  OF  THE  DIGESTIVE  CANAL 

2.  Suband  Gastritis 

Case.I. — Carl  J.,  a  joiner,  54  years  old,  entered  the  clinic  October  14, 
1902.  For  years  the  patient  had  suffered  from  pressure  in  the  stomach, 
^Yhich  was  preceded,  for  some  time,  by  frequent  vomiting  of  mucus  in  the 
morning.  The  patient  had  a  tendency  to  diarrha^i.  There  was  a  history 
of  alcoholism.  He  was  poorh'  nourished.  Physical  examination  was  nega- 
tive.    Total  acidity,  24.     There  was  only  a  weak  reaction  to  congo  paper. 

Treatment. — Rakoczy  water,  hj'drochloric  acid,  and  a  pm-ee  diet, 
resulting  in  improvement. 

Case  2. — Emily  H.,  48  years  old,  the  wife  of  a  laborer,  entered  the 
clinic  April  1st,  1903.  She  had  suffered  from  stomach  trouble  for  twenty 
years,  with  gastric  pressure  in  the  epigastrium  from  one  to  one  and  one- 
half  or  two  hours  after  eating  solids, — such  as  tough  meats,  potatoes,  bread, 
cheese,  etc.  Of  late  she  had  suffered  much  from  diarrhoea,  associated  with 
crampy  pains.  There  was  always  a  tendency  to  vomiting.  The  teeth  of 
the  patient  were  in  poor  condition.  She  had  undergone  many  privations, 
with  irregular,  impoverished  meals.    Total  acidity  of  the  test-breakfast,  34. 

Treatment. — Rakoczy  water,  belladonna  to  combat  the  crampy  pains, 
and  a  constipating  diet.  The  improvement  was  only  temporary,  as  after 
errors  of  diet.^for  instance,  after  eating  meats,  etc., — the  patient  suffered 
again  from  pressure  in  the  stomach,  instantaneous  diarrhoea  and  distention 
of  the  abdomen. 

3.  Anacid  Gastritis 

1.   Catarrhal   Gastritis 

Case  1. — Frederick  B.,  a  tailor,  31  years  old,  had  for  two  years  suffered 
from  pressure  in  the  stomach  after  eating  solids,  and  had  an  inclination  to 
diarrhoea.  There  had  been  an  exacerbation  of  the  symptoms  for  two  weeks, 
after  he  had  eaten  currants.  Patient's  appetite  was  poor,  except  for  highly 
seasoned  foods.  He  was  emaciated  and  pale.  He  had  catarrh  of  the  apex 
of  the  right  lung.  The  greater  curvature  of  the  stomach  reached  to  the 
umbilicus.  The  microscope  showed  the  test-breakfast  to  be  poorly  digested. 
The  total  acidity  was  20. 

Treatment. — Kissingen  water;  a  diet  of  semi-solids;  and  hydro- 
chloric acid.  Five  weeks  later,  pressure  in  the  stomach  had  almost  entirely 
disappeared,  and  patient  was  discharged. 

Case  2. — Herman  B.,  a  railroad  laborer,  after  an  accident  about  one 
year  previous,  had  suffered  from  severe  pressure  in  the  stomach,  loss  of 
appetite,  emaciation  and  constipation.  There  was  a  histor}^  of  alcoholism. 
The  total  acidity  of  the  test-breakfast  was  20.  Rennin  was  positive, 
giving  a  cake-like  coagulation  in  a  dilution  of  1  to  SO,  and  a  flaky  coagula- 
tion in  a  dilution  of  1  to  160.    Pepsin-digestion  ecjualed  50  per  cent. 

After  the  use  of  Kissingen  water  for  several  months,  with  a  semi-solid 
diet  and  hydrochloric   acid,  the   patient  was  greatly  improved  in  health. 


DISEASES  OF  THE  STOMACH  107 

2.  Interstitial  Gastritis 

Case  1. — August  M.,  a  laborer,  41  years  old,  had  suffered  from  pres- 
sure in  the  stomach,  especially  after  eating  such  hard  foods  as  peas,  beans, 
cabbage,  cheese,  and  meats.  After  soups  and  liquids  there  was  an  absence 
of  all  symptoms.  He  had  occasional  diarrhoea.  The  appetite  was  poor. 
There  was  a  history  of  alcoholism.  Patient  had  a  good  physique,  but  was 
anaemic  and  emaciated.    He  had  an  ulcer  of  the  rectum.    Greater  curvature 

3-4 

of  the  stomach .    The  total  acidity  was  14.    Rennin-ferment  was  positive 

in  a  dilution  of  1  to  20.     Pej)sin-digestion  equaled  1.5  per  cent. 

After  a  treatment  with  Rakoczy  water,  hydrochloric  acid,  and  suit- 
able diet,  patient  slowly  improved. 

Case  2. — Carl  B.,  a  teamster,  34  years  old,  had  suffered  from  a  feeling 
of  fulness  in  the  epigastrium  and  loss  of  appetite  for  seven  years.  He  had 
never  vomited.  There  was  no  history  of  alcoholism.  On  account  of  his 
occupation,  he  had  eaten  hastily  and  irregularly.  He  had  had  frequent 
diarrhoea.  The  total  acidity  was  15.  The  rennin-test  was  positive  in  a  dilu- 
tion of  1  to  40.  There  was  no  improvement;  on  the  contrary,  the  total 
acidity  diminished  to  8,  the  inflammatory  process  gradually  producing 
atrophy  of  the  gastric  mucosa. 

3.  Atrophic  Gastritis 

Case  1. — Dr.  H.,  an  American  physician,  had  for  years  eaten  hastily 
and  irregularly.  He  had  used  purgative  remedies  a  great  deal.  There  was 
always  pressure  in  the  stomach  after  meals.  The  test-breakfast  was  entirely 
achylous.  The  total  acidity  was  6.  The  lab  and  pepsin  ferments  were 
absent.  After  the  rest-cure  and  the  use  of  pancreon,  and  a  gastritis-fatten- 
ing laxative  diet  followed  in  a  sanatorium,  the  symptoms  entirely  disap- 
peared.   The  achylia  gastrica  was  not  improved. 

Case  2. — Therese  B.,  a  widow  67  years  old,  had  for  two  years  suffered 
from  pressure  in  the  stomach  after  eating  solids,  but  experienced  no  dis- 
comfort after  eating  soups  or  liquids.  There  had  been  an  inclination  to 
diarrhoea,  especially  after  taking  cold.  She  had  masticated  insufficiently  for 
years,-  because  of  having  no  teeth.  Total  acidity  of  the  test-breakfast  was 
8.    There  were  traces  of  rennin  and  pepsin. 

Treatment. — Kissingen  water,  hydrochloric  acid,  and  gastritis  diet. 
A  subjective  clinical  cure  soon  resulted. 

Case  3. — Selma  S.,  a  dressmaker,  40  years  old,  had  for  eight  years 
suffered  from  stomach  trouble,  with  frequent  and  irregular  vomiting,  which 
was  not  dependent  upon  meals.  Bowels  had  been  regular.  The  appetite 
was  good.  There  was  no  gastric  discomfort  immediately  after  meals.  Dur- 
ing the  menstrual  period  the  vomiting  was  more  severe.  The  patient  had 
suffered  privations  for  years,  and  had  lived  largely  on  coffee,  bread,  and 


108  DISEASES  OF  THE  DIGESTIVE  CANAL 

lard.  She  was  very  pale  and  emaciated.  The  physical  examination  was 
negative.  The  test-breakfast  was  entirely  achylous.  The  total  acidity  was 
8.    There  was  no  rennin  nor  pepsin. 

Treatment. — llakoczy  water,  hydrochloric  acid,  and  semi-solid  diet. 
Ten  days  later,  there  was  an  improvement  in  the  general  condition  of  her 
health.  She  vomited  a  stale  liquid  only  once  during  the  menses.  After 
twenty  days'  treatment  the  patient  was  absolutely  free  from  discomfort 
and  had  gained  in  weight. 

Ulcer  of  the  Stomach 

Clinical  and  Pathological  Remarks. — An  ulcer  of  the  stom- 
ach represents  a  loss  of  substance  in  the  mucous  membrane, 
and  varies  in  size  from  the  head  of  a  pin  to  the  palm  of  the  hand. 
It  is  generally  situated  on  the  lesser  curvature,  in  the  pyloric 
antrum,  or  in  the  pjdorus;  and,  more  rarely,  in  the  other  parts 
of  the  stomach. 

Ulcers  which  are  found  outside  of  the  stomach  in  the 
cardiac  end  of  the  oesophagus  and  in  the  duodenum  are,  because 
of  their  well-known  etiology,  also  called  "peptic"  ulcers. 

The  above-mentioned  breaks  in  the  continuity  of  the 
mucous  membrane  vary  in  quality  as  well  as  in  size.  For 
instance,  erosions  of  the  pars  pylorica  occur  (similar  to  erosions 
of  the  lips,  nose,  and  mucous  membrane  of  the  mouth  and 
rectum),  which  very  frequently  produce  the  same  clinical 
phenomena  as  ulceration  of  the  stomach. 

Still  further  distinctions  should  be  made  in  the  pathology 
of  ulcers,  such  as  between  the  mucous  ulcer  occuring  in  chlorosis, 
the  simple  peptic  ulcer  without  indurated  edges,  and  the  chronic 
indurated  ulcer.     Multiple  ulcers  may  exist  at  the  same  time. 

Etiology. — The  etiology  of  ulceration  of  the  stomach  is 
so  obscure  that  the  exact  cause  is  often  impossible  to  estab- 
lish; but  in  every  individual  case,  the  ability  to  do  this  would  be 
most  desirable,  so  that  the  therapy  might  be  properly  directed. 

Aside  from  infectious  diseases,  such  as  tuberculosis  and 
syphilis,  there  are  two  great  etiological  factors : 

1.  Disturbances  of  the  circulation,  which  appear  in  chlo- 
rosis, at  the  beginning  of  menstruation,  and  at  the  climacte- 
rium or  the  cessation  of  the  menses. 


DISEASES  OF  THE  STOMACH  109 

2.  Mechanical  influences. 

Besides  these,  acid  gastritis  and  syphilis  are  important 
etiological  factors  which  demand  special  consideration  in  men. 

Concerning  the  etiology  of  ulcer  of  the  stomach,  Rosen- 
heim gives  the  following  summary: 

"The  predisposing  causal  factor  of  ulceration  of  the 
stomach  is  a  local  reduction  in  the  resistance  of  the  walls  of 
the  stomach,  caused  by  some  disturbance  in  the  circulation 
that  weakens  the  resistance  of  the  stomach-wall  against  the 
digestive  power  of  the  gastric  juice. " 

I  agree  with  Rosenheim  in  that  he,  contrary  to  other 
authorities,  does  not  assume  hyperacidity  to  be  the  cause  of 
ulcer,  for  the  reason  that  normal  as  well  as  hyperacid  gastric 
juice  has  the  ability  to  digest  the  mucous  membrane,  the 
resistance  of  which  has  been  weakened. 

According  to  the  above  principles,  therefore,  most  ulcers 
of  the  stomach  may  be  classified,  according  to  their  etiology, 
in  either  the  chlorotic  or  the  climacteric  group  of  ulcers,  or 
as  ulcers  caused  by  mechanical  or  catarrhal  influences. 

Such  a  classification  naturally  explains  why  ulcers  of  the 
first  group  are  most  frequent  in  the  female  sex,  and  especially 
in  young  girls;  and  why  ulcers  of  the  second  group  usually 
affect  men,  especially  those  who  have  indulged  in  excessive 
eating,  smoking  and  drinking,  and  particularly  those  whose 
occupation  requires  chronic  pressure  upon  the  epigastrium. 
To  this  last  group  belong  shoemakers,  locksmiths,  street- 
cleaners,  masons,  bookkeepers  and,  in  short,  all  those  whose 
occupation  calls  for  the  pressure  of  solid  objects  against  the 
epigastrium,  or  who  sit  in  a  bent  position.  The  same  bad  effects 
may  be  attributed  to  corsets  and  tight  bands  around  the  body. 

The  assumption  which  was  formerly  so  popular, — that 
ulcer  was  the  result  of  chemicothermic  influences,  wdiich 
partly  explained  the  frequency  of  ulcer  in  cooks,  for  example, — 
is  now  seldom  considered. 

Ulcers  may  naturally  be  caused  by  the  corrosive  action 
of  the  various  intoxications,  especially  ulceration  of  the 
oesophagus.     These  acute  ulcers  may  become  chronic. 


110  DISEASES  OF  THE  DIGESTIVE  CANAL 

Acute  traumata  also  play  a  role  in  the  development  of 
ulceratioii  of  the  stomach.  Violence  upon  the  epigastrium 
causes  either  a  necrosis  of  the  mucosa  by  pressure  against  the 
spinal  vertebrae,  the  formation  of  hipmatoma,  or  from  suggil- 
lation  of  the  submucosa.  In  any  of  these  instances,  the  gastric 
juice  digests  that  portion  of  the  mucosa  whose  resistance  has 
been  lowered  by  injury. 

This  form  of  ulcer  may,  under  unfavorable  conditions  and 
improper  treatment,  become  chronic  and  lead  to  cicatricial 
formation,  as  well  as  other  complications  and  sequela^,  and 
even  to  carcinomata,  as  in  the  case  of  any  other  kind  of  ulcer. 

Hyperchlorhydria,  as  such,  never  causes  peptic  ulcer. 

It  is  very  frequently  rather  the  result  of  an  ulcer  of  the 
pylorus,  for  the  reason  that  the  latter  causes  a  spastic  stenosis 
of  the  pjdorus  with  food-retention,  and  a  consequent  irrita- 
tion of  the  gastric  glands. 

Not  until  the  mucous  membrane  of  the  stomach  has  been 
weakened  in  some  way, — for  example,  by  inflammatory 
processes,  in  acid  gastritis, — may  there  be,  besides  the  hyper- 
chlorhydria, a  development  of  erosions  of  the  mucosa. 

In  comparison  with  the  extreme  frequency  of  hyper- 
acidity, there  are  but  few  cases  of  ulcer.  As  an  example, 
symptoms  of  ulcer  never  appear  in  cases  of  nervous  hyper- 
acidity, even  if  the  latter  should  exist  for  decades. 

In  many  cases  it  is  very  difficult  to  differentiate  between 
actual  ulcers  and  erosions  or  fissures  of  the  mucosa.  Concern- 
ing this.  Boas  says: 

"CUnically,  the  view  is  thoroughly  estabhshed  that 
hemorrhagic  erosions  can  produce  exactly  the  same  symptoms 
as  ulcer,  even  fatal  bleeding." 

In  doubtful  cases,  therefore,  treatment  must  always  be 
that  of  ulcer. 

Sijmptomatology.—l,   Subjective;    2,   Objective. 

1.  Patients  complain  of  actual  pain  in  the  epigastrium 
which  is  of  a  crampy,  cutting,  boring,  or  burning  character. 
It  begins  anteriorly  and  radiates  along  the  sternum  or  around 
both  sides  of  the  body  to  as  low  as  the  sacrum  or  as  high  as  the 


DISEASES  OF  THE  STOMACH  111 

left  shoulder.  The  pain  scarcely  ever  occurs  immediately  after 
swallowing,  but  from  one-half  hour  to  four  hours  after  eating. 

This  symptom  -  complex  should,  according  to  Buch,  be 
designated  as  epigastralgia  rather  than  gastralgia,  to  prevent 
the  assumption  in  the  mind  of  the  physician  that  the  source 
of  the  pain  is  in  the  stomach. 

Attacks  of  pain  always  occur  at  the  same  hour  after 
eating  in  each  case,  although  different  patients  may  suffer  at 
different  intervals  after  eating, — for  instance,  in  case  ''X, " 
one  hour  after  raeals;  in  case  ''Y,"  two  or  three  hours  after; 
and  in  case  "Z,"  several  hours  after  eating,  when  the  stomach 
is  empty,  etc. 

Epigastralgia  occurring  at  a  definite 
time  after  eating  is  the  most  positive 
symptom    of   gastric    ulcer. 

Gastric  hemorrhage  is  even  less  diagnostic  as  a  symptom, 
for  the  reason  that  it  may  occur  as  well  in  diseases  of  the 
liver,  and  in  passive  congestion  in  disturbances  of  the  greater 
circulatory  system;  while  gastric  pain  occurring  at  a  definite 
time  after  meals  occurs  exclusively  in  ulcer  of  the  stomach. 

The  intensity  of  the  pain  always  depends  upon  the  quality 
of  the  food  eaten;  the  coarser  the  food,  the  more  severe  the 
pain.  After  liquid  foods,  there  may  be  no  pain;  or  there  may 
even  be,  in  slight  cases,  a  mitigation  of .  pain  immediately 
after  eating,  because  the  food  combines  with  and  neutralizes 
the  excessive  amount  of  acid  of  the  stomach. 

In  ulcer  of  the  pylorus,  pain  does  not  occur,  as  a  rule, 
for  some  time  after  eating, — from  two  to  four  hours;  and  is 
frequently  accompanied  by  vomiting  of  the  acid  gastric  juice, 
after  which  it  is  relieved.  The  patient  sometimes  artificially 
produces  vomiting  by  tickling  the  pharynx  with  the  finger  in 
order  to  obtain  this  relief.  These  are  the  cases  in  which,  in 
addition  to  the  organic  lesion  of  the  pylorus,  there  occurs  at 
the  height  of  digestion  a  pylorospasm,  as  we  will  give  in  greater 
detail  below. 

Such  attacks  of  pain  cease  after  the  acid  contents  of  the 
stomach  are  vomited,  which  generally  occurs  in  the  evening 


112  DISEASES  OF  THE  DIGESTIVE  CANAL 

between  6:00  ami  7:00  o'clock,  and  at  night  between  1:00 
and  3:00  o'clock,  at  a  time  when  there  should  be  no  food- 
remnants  in  the  stomach.  Frequently  in  these  cases  the  ulcer 
is  already  partially  cicatrized,— which  sometimes  causes  the 
food-stasis. 

If  not  rationally  treated,  many  such  cases  sooner  or  later 
lead  to  a  dilatation  of  the  stomach,  secondary  to  the  pyloric 
stenosis.  It  would,  therefore,  be  a  great  mistake  to  assume 
that  pain  occurring  before  eating  was  due  to  a  gastric  neurosis, 
and  to  conduct  the  treatment  accordingly.  As  a  result  of 
such  irrational  therapy,  a  fatal  hsematemesis  might  occur. 

The  periodicity  of  an  epigastralgia  is  also  characteristic 
of  ulcer.  Patients  may  suffer  for  weeks  at  a  time  from  gastral- 
gia  after  eating,  and  then  feel  perfectly  well  for  several  months. 

These  periods  of  pain,  for  reasons  which  are  unknown, 
very  frequently  occur  in  the  spring  and  autumn.  They  are 
to  be  naturally  explained  by  the  fact  that  they  are  dependent 
upon  the  return  of  the  ulcer,  disappearing  as  soon  as  it  is 
cured  by  suitable  treatment,  and  returning  if  errors  in  diet 
are  committed. 

Menstruation  and  pregnancy  also  modify  the  pain  of 
ulcer, — which  fact  is  explained  by  the  increased  amount  of 
blood  in  the  pelvic  organs  at  these  times.  The  pains  of  ulcer 
are,  in  general,  decreased  in  profuse  menstruation  and  increased 
when  there  is  a  lessened  menstrual  flow;  while  in  pregnancy, 
pain  is  sometimes  entirely  absent. 

It  is  also  worthy  of  mention  that  vicarious  menstruation  sometimes 
occurs  from  the  stomach.  Kuttner  and  other  authors  have  pointed  out 
that  these  cases  represent  a  diagnostic  predisposition  to  ulcer,  as  exhibited 
by  the  locus  minoris  resisteniice  in  the  mucous  membrane  of  the  stomach. 

Only  when  a  peptic  ulcer  is  situated  at  the  cardia  does 
epigastralgia  occur  immediately  after  swallowing. 

The  appetite  is,  as  a  rule,  quite  good  in  ulcer-patients, 
but  very  frequently  the  fear  of  eating  causes  emaciation,  which 
is  inversely  proportionate  to  the  amount  of  food  eaten. 

The  bowels  are  generally  constipated  in  ulcer  of  the 
stomach. 


DISEASES  OF  THE  STOMACH  113 

Vomiting  is  not  a  common  symptom,  although  it  usually 
occurs  in  severe  cases  a  few  hours  after  eating,  if  the  food  is 
too  irritating  in  character. 

In  regard  to  htematemesis  and  melsena:  according  to  the 
statements  of  patients,  these  symptoms  by  no  means  occur  in 
every  case  of  ulcer,  but,  on  the  contrary,  are  relatively  in- 
frequent. The  history  of  patients  to  the  effect  that  they  have 
vomited  blood,  or  have  passed  tarry  stools,  is  of  pathological 
value  only  when  the  blood  vomited  is  of  a  dark  color,  or  when 
epigastralgia  has  preceded  the  vomiting  for  a  long  period. 

Vomiting  of  blood  without  a  preceding  epigastralgia  is 
typical,  rather,  of  hemorrhage  from  passive  hypersemia  of  the 
gastric  mucosa,  or  of  cancer. 

2.  The  objective  symptoms  include,  first  of  all,  hemor- 
rhages,— provided  that  the  physician  has  the  opportunity  to 
observe  them;  or  the  demonstration  of  occult  blood  in  the 
vomitus  or  faeces,  according  to  the  method  of  Boas,  which  has 
been  described  in  the  General  Section  (see  page  41). 

The  second  objective  symptom  of  ulcer  is  a  circumscribed 
tenderness  in  the  epigastrium. 

To  demonstrate  this,  the  physician  should  exert  strong 
pressure  with  the  forefinger  upon  every  part  of  the  epigastrium, 
from  the  ensiform  process  to  the  umbilicus.  From  the  state- 
ments, and  from  the  facial  expression  of  pain  of  the  patient, 
the  physician  will  usually  locate  the  sensitive  area. 

The  sensitive  area  to  the  left  of  the  tenth  dorsal  vertebra, 
which  was  first  pointed  out  by  Boas,  is  also  an  important 
finding  which  helps  to  establish  a  positive  diagnosis.  Diffuse 
sensitiveness  to  pressure  o>n  the  back  is  without  significance. 

The  third  objective  symptom  is  hyperacidity  of  the 
gastric  juice,  which  occurs  in  most  cases  of  ulcus  ventriculi. 
After  the  Boas-Ewalcl  test-breakfast,  it  amounts  to  from 
70  to  100,  and  to  considerably  more  after  the  test-dinner. 

There  are,  however,  a  number  of  cases  that  have  a  normal 
acidity,  especially  recent  cases, — which  goes  to  prove,  contrary 
to  the  assumption  of  many,  that  the  ulcer  is  primary  to  the  hy- 
perchlorhydria  and  that  it  is  also  the  cause  of  the  epigastralgia. 


114 


DISEASES  OF  THE  DIGESTIVE  CANAL 


A  marked  reduction  of  the  total  acidity  of  the  Boas- 
Ewald  test-breakfast,  in  cases  of  ulcer,  should  always  awaken 
a  suspicion  of  malignant  degeneration  of  the  ulcer. 

Ulceration  of  the  duodenum  causes  precisely  the  same 
symptoms  as  ulcer  of  the  pylorus,  so  that  an  absolute  difTer- 

FiG.  24. 


Typical  i)re-~\ire  point  in  gastric  ulcer. 

entiation  is  rarely  possible.  From  a  practical  standpoint, 
however,  this  is  not  actually  essential,  because  the  treatment 
is  the  same  in  both  diseases. 

Jaundice,  appearing  in  a  case  of  probable  ulcer,  renders 
the  diagnosis  more  certain. 

Diagnosis. — In  uncomplicated  cases,  the  diagnosis  of  ulcer 
of  the  stomach  from  the  symptomatologj^  is  usually  very  easy. 


DISEASES  OF  THE  STOMACH  115 

In  women  in  the  chlorotic  or  climacteric  periods  of  life, 

the  diagnosis  of  ulcus  chloroticum  and  dimactericum  may 
always  be  made  when  epigastralgia  occurs  at  a  definite  time 
after  taking  food,  especially  solids.  These  cases  should  be 
treated  as  ulcer,  whether  hsematemesis  has  occurred  or  not. 

Compression-ulcer,  or  ulcus  decubitale,  is  diagnosed: 
(1)  When  the  anamnesis  gives  an  etiological  factor;  (2)  when 
severe,  cramp-like  pains  occur  one  to  three  hours  after  eating. 

The  diagnosis  of  catarrhal  ulcer  is  made  in  drinkers, 
smokers,  and  gormands,  who  present  the  above  symptoms. 

The  diagnosis  of  ulcer  of  the  stomach  is  made  certain  if 
hsematemesis  and  melsena  occur,  or  if  the  analysis  of  the 
gastric  juice  shows  hyperacidity. 

The  latter  condition,  in  cases  of  chlorotic  ulcer,  cannot 
be  determined,  since  it  is  unsafe  to  introduce  the  stomach- 
tube  on  account  of  the  danger  of  perforation. 

All  other  symptoms  are  entirely  accessory  and  subordi- 
nate to  the  above,  with  the  exception  of  localized  points  of 
tenderness  in  the  epigastrium,  and  in  the  area  to  the  left  of 
the  tenth  to  the  twelfth  dorsal  vertebra.     , 

Differential  Diagnosis. — In  the  differential  diagnosis,  hem- 
orrhage should  be  first  considered.  As  already  mentioned, 
hemorrhage  from  passive  congestion  in  diseases  of  the  heart, 
cirrhosis  of  the  liver,  vicarious  menstruation  from  the  gastric 
mucosa,  and  hsematemesis  in  pulmonary  affections,  must  be 
differentiated  from  the  hemorrhage  of  peptic  ulcer. 

In  connection  with  epigastralgia,  we  should  especially 
consider  the  pain  which  occurs  in  three  other  affections: 

1.  Angina  Pectoris. — The  pain  associated  with  this  affection  is  fre- 
quently described  by  the  patient  as  "stomach  cramps."  It  occurs  chiefly 
in  advanced  age,  and  in  those  with  arteriosclerosis.  The  pain  usually  sets 
in  after  overloading  the  stomach,  especially  with  flatulent  foods ;  after  using 
coffee  or  tobacco;  or  after  over-exercise.  The  pain  in  this  disease,  however, 
radiates  to  the  left  arm  behind  the  sternum  and  the  region  of  the  heart. 
It  does  not  occur  with  regularity,  as  in  ulcer,  and  is  generally  independent 
of  the  nature  of  the  diet. 

2.  Cholelithiasis. — In  cholelithiasis,  epigastralgia  is  paroxj'smal  and 
sporadic.     It  comes  on  like  a  thunder-bolt  from  a  clear  sky;   usually  after 


116  DISEASES  OF  THE  DIGESTIVE  CANAL 

mental  excitement  or  errors  in  diet.  The  anamnesis  in  this  disease  also 
shows  that  there  has  been  no  regularity  in  the  attacks.  Patients  suffering 
from  cholelithiasis  often  describe  such  attacks  of  pain  as  "stomach  cramps." 
[See  editorial  note  on  dyspei)tic  symptoms  of  gall-bladder  disease.] 

3.  Intestinal  Colic. — The  pain  in  intestinal  colic  is  dependent  upon 
the  condition  of  the  bowels.  It  occurs  in  constipation  as  well  as  in  diar- 
rhoea, and  the  pain  is  usually  relieved  by  a  movement  of  the  bowels,  or  by 
the  escape  of  gas.  (See  details  in  the  section  on  Intestinal  Diseases.)  In 
patients  who  suffer  from  chronic  gastritis  and  intestinal  catarrh,  intestinal 
colic  sometimes  occurs  a  .short  time  after  the  partaking  of  indigestible  food 
and  cold  drinks;  it  is  produced  reflexly  and  may  easily  be  confused  with 
the  epigastralgia  of  ulcer.  It  persists,  however,  for  a  short  time  only  and 
is  always  associated  ivith  disturbances  of  the  intestine. 

There  are,  in  addition,  a  considerable  number  of  other 
affections  that  must  always  be  considered  in  the  differential 
diagnosis  of  epigastralgia,  such  as  pancreatic  calculi,  emboli  of 
the  blood-vessels  of  the  mesentery,  lead  colic,  etc.  The  lim- 
ited space  of  this  work  will  not  permit  a  more  detailed  consid- 
eration of  the  diagnosis  of  these  affections. 

The  vomiting  which  occurs  in  ulcer  of  the  stomach  must 
be  frequently  differentiated  from  nervous  vomiting,  and  from 
that  which  accompanies  the  gastric  crises  of  tabes  dorsalis. 

A  great  many  other  affections  produce  symptoms  similar 
to  ulcer,  which  explains  why  ulcer  is  so  frequently  diagnos- 
ticated when  it  does  not  exist,  and  vice  versa. 

The  most  important  diagnostic  sign  of  gastric  ulcer  is  the 
occurrence  of  severe,  cramp-like,  boring,  or  cutting  pains  in  the 
epigastrium,  which  radiate  to  the  sides  and  back  and  which  ap- 
pear regularly  at  a  certain  time  after  meals.  This  is  the  only 
symptom  of  ulcer  that  may  not  be  simulated  by  other  diseases. 

Complications  of  Ulcer  of  the  Stomach 

1.  Perforation. — This  occurs  but  rarely,  and  then  mostly 
in  cases  of  chlorotic  ulcer.  It  is  for  this  reason  that  we  advise 
the  physician  not  to  introduce  the  stomach-tube. 

The  danger  of  perforation  is  proportionate  to  the  amount 
of  food  in  the  stomach  at  the  time  of  perforation;  therefore, 
the  earlier  it  occurs  after  eating,  the  more  urgent  the  need  of 
surgical  treatment. 


DISEASES  OF  THE  STOMACH  117 

Perforations  which  occur  in  the  empty  stomach,  how- 
ever, may  be  treated  expectantly,  for  the  reason  that  the 
empty  stomach  contains  relatively  few  pathogenic  micro- 
organisms.* 

[The  improved  surgical  technic  in  the  treatment  of  per- 
foration of  gastric  and  duodenal  ulcer,  and  the  remarkable 
success  in  this  field  of  surgery,  scarcely  justify  the  dependence 
upon  expectant  treatment  in  any  case.  If  perforation  of  an 
ulcer  occurs,  it  becomes  a  surgical  affection,  and  operation 
should  be  resorted  to  within  twelve  hours,  if  possible.  In 
data  collected  by  Musser,  the  mortality  following  182  cases, 
in  which  operation  was  performed  from  one  to  twelve  hours 
after  perforation,  was  26.3  per  cent.;  while  the  general  mor- 
tality in  481  operations  performed  from  one  hour  to  four 
weeks  after  perforation,  was  34.3  per  cent. 

In  55  cases  without  operation,  the  mortahty  was  54.5 
per  cent.f] 

The  most  striking  symptom  of  perforation  is  sudden 
abdominal   pain. 

2.  Pyloric  Spasm. — This  is  a  very  frequent  compHcation 
of  ulcer  of  the  pylorus,  and  is  caused  in  the  same  way  as  spasm 
of  the  sphincter  ani  in  fissures  of  the  anus. 

Pyloric  spasm  causes  motor  insufficiency,  hypersecretion 
of  gastric  juice,  and  dilatation  of  the  stomach,  as  will  be 
described  below. 

3.  Cicatricial  Formation. — If  scars  occupy  the  region  of  the 
pylorus,  and  are  situated  in  the  duodenum,  they  also  produce 
motor  insufficiency  of  the  stomach,  hypersecretion,  and  ectasia. 

"Hour-glass  stomach"  also  results  from  scar -formation 
[see  Fig.  25]. 

4.  Perigastritis. — If  the  ulcerative  process  extends  to 
the  serous  coat  of  the  stomach-wall,  adhesions  to  neighboring 
organs  result,  i.e.,  perigastritis.     Such  adhesions  may  impair 

*  Perforation  of  the  empty  stomach  occm-s,  for  instance,  in  clilorotic 
female  servants  who  perform  heavy  labor,  such  as  scrubbing,  wasliing,  cleaning 
windows,  etc.,  early  in  the  morning  before  breakfast. 

[t Musser. — Medical  vs.  Surgical  Treatment  of  Gastric  Ulcer. — "Trans- 
actions of  the  Congress  of  American  Physicians  and  Surgeons,"  1907,  Vol.  vii.] 


118 


DISEASES  OF  THE  DIGESTIVE  CANAL 


the  motility  of  the  pars  pylorica,  which  in  turn  causes  motor 
insufficienc}'  and  dilatation  of  the  stomach. 

Adhesions  between  the  fundus  of  the  stomach  and  the 
neighboring  organs,  as  a  rule,  do  not  cause  any  symptoms  of 
importance.  Fistula3  between  the  stomach  and  the  trans- 
verse colon,  and  the  formation  of  subphrenic  abscesses  also 
result  from  perigastritis. 


Fig.  25. 


SlefiosLso/'  /^:/ori/A- 


Df/alaiio/i  '^f\^^  S 


Hour-frlass  contraction  of  the  stomach,  cicatricial  stenosis  of  the  pylorus  and  cardia  with 
dilatation  of  tlie  cc^^ophagus,  secondary  to  multiple  round  ulcer  of  the  stomach.  [Courtesy  of 
W.  A.  Edwaxds,  M.D.,  Los  Angeles.] 


5.  Malignant  Degeneration  of  Ulcer. — Carcinomatous  de- 
generation of  ulcer  often  occurs  in  persons  of  advanced  age. 
Ulcers  of  the  pylorus  and  of  the  smaller  curvature  most  fre- 
quently undergo  malignant  degeneration;  and  ulcers  of  the 
cardia,  less  freciuently.  Ulcers  caused  by  acute  traumata  of 
the  stomach  may  also  undergo  carcinomatous  changes;  such 
cancers  are,  therefore,  of  traumatic  origin.  Cases  are  naturally 
observed,  however,  in  which  there  is  no  positive  evidence  of 
the  origin  of  cancer  after  trauma. 


DISEASES  OF  THE  STOMACH  119 

Treatment 

1.  Hygienic  and  Dietetic  Treatment. — First  of  all,  the 
causes  which  were  responsible  for  the  development  of  ulcer 
should  be  removed.  Corsets  and  skirt-bands  are  forbidden; 
and  the  clothing  should  be  supported  entirely  from  the 
shoulders.  Occupations  which  require  constant  pressure 
upon  the  epigastrium,  and  sitting  in  a  bent-over  position, 
must  be  given  up. 

Diet:  Leube's  ulcer-diet  is,  at  the  present  time,  highly- 
esteemed. 

In  the  dietetic  treatment  of  ulcer,  four  forms  of  food 
should  be  used;  liquid,  pappy,  soft,  and  semi-solid.  Each  of 
these  forms  should  be  continued  from  seven  to  ten  days. 

In  addition,  it  should  be  mentioned  that  in  persistent 
cases  of  ulcer,  a  prolonged  fast  must  be  observed.  The 
nourishment  in  these  cases  should  be  given  in  the  form  of 
nutritive  enemata. 

The  following  nutritive  enema  of  Boas  should  be  given 
three  times  daily: 

One-quarter  litre  of  milk  at  the  body-temperature;  the 
yolks  of  two  eggs;  one  tablespoonful  of  white  flour;  one 
tablespoonful  of  red  wine,  and  a  pinch  of  table  salt, — to  be 
well  mixed  by  stirring. 

It  is  usually  found  that  rectal  nourishment  cannot  be 
continued  indefinitely,  as  intertrigo  ani  is  likely  to  occur. 

The  first  of  the  above  mentioned  forms  of  diet  should 
be  prescribed  while  the  patient  is  at  absolute  rest  in 
bed,  for  the  reason  that  this  diet  will  not  furnish  a  requisite 
number  of  calories  of  food  for  the  maintenance  of  the  body. 

There  are,  naturally,  severe  cases  of  ulcer  in  which  the 
individual  forms  of  diet  should  be  continued  from  two  to 
three  weeks,  instead  of  the  period  mentioned  above.  As  a 
rule,  six  meals  should  be  given  daily;  two  forenoon  meals, 
a  mid-day  meal,  two  afternoon  meals,  and  supper.  Every 
patient,  even  the  least  intelligent,  can  easily  follow  out  this 
treatment  for  himself. 


120  DISEASES  OF  THE  DIGESTIVE  CANAL 

1st  Form. — The  first  form  of  diet  should  include  the  following  foods: 
milk,  milk  and  bread  soups,  tea  with  cream,  or  cocoa  cooked  with  cream; 
the  various  cereals, — oatmeal,  rice,  wheat  and  corn-meal.  Butter  may  be 
used  with  all  foods.  Patients  of  the  better  classes  may,  in  addition  to  the 
above,  use  sanatogen,  puro,  malted  milk,  malted  nuts,  and  the  various 
artificial  preparations  of  casein  as  substitutes  for  meat.  In  many  cases 
very  good  results  are  obtained  with  the  milk-diet, — two  or  three  litres 
being  used  daily. 

27id  Form. — In  the  second  period  of  the  tlict,  the  patient  may  be  given 
calves'  brain,  chicken  and  pigeon,  as  well  as  scraped  ham;  rice  and  sago  in 
beef  tea,  various  broths  made  from  cereals,  softened  zwieback;  and  a 
liberal  quantity  of  butter  at  every  meal. 

Srd  Form. — Fillet,  mutton  chops  broiled  or  cooked  rare  in  butter, 
boiled  veal,  roast  chicken  and  pigeon,  soft  eggs,  and  purees  of  potato, 
spinach,  carrots,  green  peas,  asparagus  and  cauliflower  with  butter,  and 
white  bread. 

4th  Form. — This  form  consists  of  light  breads,  grits,  cereals,  rice  pud- 
ding; such  fruit  sauces  as  raspberry  juice  and  cherries;  deer,  partridge, 
and  lean  fish,^such  as  pike,  perch,  and  trout. 

Sweet  sauces  prepared  as  purees  may  be  used  in  this  form,  as  well  as 
in  the  second  and  third  forms  of  diet. 

When  all  of  these  forms  are  well  borne  by  the  patient, 
he  may  gradually  be  given  the  ordinary  mixed  diet.  It  is 
necessary,  for  several  months,  however,  to  avoid  coarse 
breads,  fried  potatoes,  acids,  pastries,  cabbage,  cheese,  goose, 
duck,  fat  pork,  ham,  bacon,  eel,  salmon,  legumes,  and  in 
short,  all  hard,  indigestible  foods. 

Small  amounts  of  wine,  slightly  warmed  and  diluted  with 
water,  are  allowed,  as  well  as  lemonade  or  raspberryade; 
while  beer,  and  all  other  forms  of  alcohol,  are  interdicted. 

There  are  still  a  large  number  of  patients  who,  on  account 
of  social  conditions,  are  unable  to  have  the  advantage  of  the 
rest-cure,  to  carry  out  the  proper  dietary.  In  these  cases, 
ambulatory  treatment  must  be  given  in  order  that  they  may 
retain  their  vocations,  etc. 

Patients  undergoing  an  ambulatory  treatment  for  ulcer, 
will,  of  course,  become  considerably  reduced  in  weight  during 
the  first  period  of  treatment. 

2.  Medicothermal  Treatment. — Lavage  is  an  unnecessary 
procedure  in  uncomplicated  ulcer  of  the  stomach,  although 


DISEASES  OF  THE  STOMACH  121 

a  few  clinicians  have  attempted  to  control  hemorrhage  by 
lavaging  the  stomach  with  ice-water. 

Applications  and  compresses  have  long  been  used  exter- 
nally. In  acute  exacerbation  of  ulcer,  and  in  hemorrhage 
from  the  stomach,  ice-compresses  are  indicated;  while  in 
chronic  cases,  hot  applications,  such  as  seed-meal  poultices, 
etc.,  as  well  as  thermal  coils,  offer  good  service. 

The  compresses  should  be  apphed  during  the  entire  day, 
as  hot  as  possible,  and  replaced  at  night  by  a  Priessnitz 
bandage.  Should  blistering  occur  from  the  hot  applications, 
soothing  salves  and  powders  should  be  used. 

The  physician  will  determine  whether  the  compresses 
have  been  properly  applied  if  the  skin  of  the  epigastrium  shows 
a  brown  coloration. 

3.  Balneological  Treatment. — In  all  forms  of  benign 
ulceration  of  the  stomach,  Carlsbad,  Neuenahr  and  Vichy 
waters  are  indicated.  Whenever  it  is  possible,  the  patient 
should  be  sent  direct  to  these  watering-places.  If  this  is  not 
practicable,  these  waters  may  be  used  at  home  at  a  tempera- 
ture of  about  35°  R.  [112°  F.], — two  glasses  each  containing 
about  200  c.c.  in  the  morning,  and  one  glass  before  the  mid- 
day and  one  before  the  evening  meal.  Patients  in  poor  cir- 
cumstances may  be  given  the  genuine  spring-water  salts  or 
the  artificially  prepared  salts  in  the  same  manner.  Vichy  water 
and  salts  should  be  given  to  those  with  weak  constitutions. 

The  mineral  waters  are  to  be  used  before  meals,  in  order 
to  affect  directly  the  glands  of  the  mucosa,  rather  than  to 
neutralize  the  excessive  acidity  of  the  stomach,  to  accomplish 
which,  alkalies  should  be  given  after  meals. 

If  there  is  a  suspicion  of  malignant  degeneration  of  the 
ulcer,  i.e.,  if  there  are  symptoms  of  ulcer  combined  with  sub- 
acidity, — the  mineral-water  cure  may  be  dispensed  with. 

4.  Medicinal  Treatment. — In  the  treatment  of  gastric 
ulcer,  there  are  two  drugs  of  especial  value, — nitrate  of  silver 
and  subnitrate  of  bismuth.  As  a  general  rule,  the  former 
should  be  given  for  acute  chlorotic  ulcer;  and  bismuth,  in  the 
other  forms  of  ulcer,  as  per  the  following  prescriptions: 


122  DISEASES  OF  THE  DIGESTIVE  CANAL 

1.  J\     Sol.  argenti  nitratis — gr.  viiss:  oviss     0.5:200.0 

M.  ad.  vitr.  nigr. 
Sig. — One  tablespoonful  (porcelain)  in  a  wineglassful  of 
water,  J  to  i  hour  before  meals. 

2.  rj    Bismuth!  subnitratis,  oiiiss  100.0 
Sig." — One  leaspoonful  in  a  glass  of  warm  water, 

stirred  well,  before  breakfast.    Lie  on  right  side 
one-half  hour  after  taking. 

These  drugs  generall}''  suffice  in  the  treatment  of  patients 
who  are  able  to  take  proper  care  of  themselves. 

If  pain  is  not  relieved  by  the  above  treatment,  it  is  best 
to  prescribe  belladonna  combined  with  bismuth  or  an  alkali, 
one  or  two  hours  after  eating,  as  follows: 

1.  I^     Extract!  belladonnse  foliorum,  gr.  iii-v  0.2-0.3 

Magnesii  oxidi, 

Sodii  bicarbonatis,  fifi,  5vi  25.0 

M.  ft.     Sig. — A  teaspoonful  one  or  two  hours  after 
meals,  two  or  three  times  daily. 

2.  I^     Extracti  belladonnre  foliorum,  gr.  iii  0.2 

Bismutlii  subnitratis,  5iv  15.0 

M.     Sig. — A  knifepoint  of  the  powder  after  meals. 

If  spasms  of  the  pylorus  complicate  the  clinical  course  of 
ulcer,  from  one-half  to  one  wineglassful  of  olive  oil  should  be 
given  in  the  morning  before  breakfast,  and  from  one  to  two 
teaspoonfuls  before  the  mid-day  and  evening  meals.  The  oil 
may  be  prescribed  in  the  following  manner  to  patients  who 
have  fastidious  palates: 

I^     Tincturse  belladonna?  foliorum,  oi-iss       5.0-  6.0 
Olei  amygdalae  dulcis,  oi-iss  30.0—10.0 

Vitelli  ovi  unius  or  duo, 
Aqufe  destillatse,  q.s.  adoviss  200.0 

M.  ft.  emulsio.     Sig. — A  tablespoonful  before  eat- 
ing, t.i.d.     (Hoppe,  of  Hanover.) 

I  have  successfully  treated  many  cases  of  ulcer  by  the 
olive-oil  treatment  after  other  measures  had  been  exhausted, 
especially  in  patients  who  had  not  taken  the  rest-cure.* 

*  Good  results  from  this  oil-treatment,  which  I  introduced,  have  been 
obtained  in  chronic  ulcer,  by  Hoppe  of  Hanover,  Wygodzinski  of  Beuthen, 
Van  Lauwe  of  Roulers,  Walkow  of  Prag,  Roder  of  Berlin,  and  many  others. 


DISEASES  OF  THE  STOMACH  123 

To  neutralize  the  hyperacidity  of  the  gastric  juice,  the 
mastication  tablets,  mentioned  on  page  100,  should  be  used 
immediately  after  eating, — as  well  as  sodium  bicarbonate  or 
magnesium  ammonium  phosphate,  one  or  two  hours  after 
eating.  According  to  the  experience  of  Bourget,  the  follow- 
ing prescriptions  are  suitable: 

1.  I^     Sodii  sulphatis, 

Sodii  phosphatis,  aa,  gr.  xxx       2.0 
Sodii  bicarbonatis,  oii  8.0 

M.  ft.  pulv.  No.  X.     Each  powder  should  be  dissolved 
in  one  litre  of  water. 

The   patient   should  drink   100  c.c.   of  the  warmed   solution, 
one  or  two  hours  after  each  meal. 

2.  I^     Extracti  belladonnee  foHorum,  gr.  iss  0.1 

Magnesii  oxidi,  gr.  Ixxx  ,5.0 

Sacchari,  oiiss  10.0 

Sodii  citratis.  oxi  40.0 

M.  ft.  pulv.     Sig. — A  teaspoonfiil  t.i.d. 

I  have  obtained  very  good  results  in  the  after-treatment 
,  of  ulcer  by  this  method.  Of  the  various  alkalies,  bicarbonate 
of  soda  would  be  preferably  used  if  the  patient's  bowels  are 
regular;  while  the  salts  of  magnesia  should  be  used  in  case  of 
constipation,  and  calcium  salts  for  diarrhoea,  just  as  in  acid 
gastritis  (see  page  99). 

^  5.  Surgical  Treatment. — Surgical  procedures  are  to  be 
resorted  to  in  ulcer  of  the  stomach  in  perforation  and  in  per- 
sistent hemorrhage.  On  the  other  hand,  surgical  measures 
must  very  frequently  be  employed,  as  we  shall  see  below,  in 
the  treatment  of  the  various  complications  of  ulcer,  such  as 
the  removal  of  scar-tissue  formation,  and  for  the  relief  of  the 
resulting  complications. 

OUTLINE  OF  THE  TREATMENT  OF  ULCER  OF  THE  STOMACH 

I.  Period  of  healing,  about  six  weeks. 

A.  Leube's  rest  and  liquid-diet  cure;  when  pos- 
sible, combined  with  the  use  of  Carlsbad 
water,  or  its  salts,  and  suitable  medication. 


124  DISEASES  OF  THE  DIGESTIVE  CANAL 

B.  Ambulatory  treatment,  when  Leubc's  ulcer-treat- 
ment is  not  feasible. 

a.  In  chlorotic  ulcer,  silver  nitrate  from  four  to 
six  weeks. 

6.  Subnitrate  of  bismuth  from  four  to  six  weeks, 
in  cases  of  chlorotic  ulcer  which  have  existed 
as  long  as  a  year,  and  also  in  the  other 
forms  of  ulcer. 

c.  Olive-oil  treatment  in  severe  epigastralgia 
and  hyperchlorhydria,  for  several  weeks. 
Milk  of  almonds  may  be  used  in  lieu  of  the 
oil-treatment.  Silver  nitrate  and  subnitrate 
of  bismuth  and  the  oil-treatment  should  be 
given  before  meals;  and  the  remaining 
medicaments,  particularly  belladonna  and 
antacids,  after  meals. 

II.  After-treatment,  about  forty  days. 

A.  Mineral-water    cures    at    Carlsbad    or    Vichy,    or 

conducted  at  home.  Three  or  four  glasses  of 
water  should  be  taken  daily  for  from  four  to  six 
weeks,  combined  with  a  bland,  non-irritating 
diet.  In  this  period,  the  secondary  acid  gastritis 
should  be  largely  cured. 

B.  Iron  therapy  in  cases  of  chlorotic  ulcer. 

III.  Prophylactic  period;    about  two  or  three  months. 
For  the  prevention  of  the  recurrence  of  ulcer,  the  use  of 

milk  of  almonds  before  meals,  three  times  daily,  is  indicated 
for  a  period  of  two  or  three  months. 

The  milk  of  almonds  is  prepared  as  follows: 
A  tablespoonful  of  powdered  sweet  almonds  is  emulsified 
with  one-quarter  litre  of  hot  water.     When  taken  it  should  be 
warmed  to  30°  R.  [100°  F.] 

Patients  with  less  fastidious  tastes  may  use,  instead,  three 
times  daily  before  meals,  one  teaspoonful  of  linseed  oil,  to 
which  one  drop  of  the  oil  of  mentha  has  been  added;  or  one- 
half  wineglassful  of  oil  may  be  given  in  the  morning  before 
breakfast. 


DISEASES  OF  THE  STOMACH  125 

I  have  arrived  at  the  conclusion  that  relapses  frequently 
occur  unless  after-treatment  and  prophylactic  measures  are 
strictly  observed. 

IV.  Acute  hemorrhage: 

Rest  in  bed,  application  of  ice-bags,  swallowing  of  small 
pieces  of  ice,  no  food  by  mouth  for  two  or  three  days,  during 
which  time  nutrient  enemata  may  be  given.  Iced  milk  may 
then  be  used  and  Leube's  first  diet-form  may  gradually  be 
substituted. 

Of  medicaments:  lead  acetate  and  opium,  0.3  (|  gr.) 
of  each,  four  times  daily;  stypticin,  0.3  (h  gr.),  three  times 
daily;    and  liquor  ferri,  three  to  five  drops  in  oatmeal  gruel. 

In  very  severe  hemorrhages,  a  subcutaneous  injection  of 
gelatin  should  be  given. 

Hydrastinin  and  adrenalin  may  be  tried  internally. 

The  newest  remed}^  for  hemorrhage,  according  to  Klemp- 
erer,  is  estalin,  an  albumin  preparation.  Four  or  five  tablets 
of  estalin  are  dissolved  in  100  c.c.  of  water  and  taken  early  in 
the  morning  on  an  empty  stomach. 

1.  I^     Gelatini,  oiss  50.0 

Eleosacchari  citri,  5  xi  45.0 

Suprarenin  (of  a  one  per  mille  solution),  gtts.  Ixxx  5.0 

Aquae  destillatse,  o  xvss  4.50.0 
Sig. — A  tablespoonful  every  three  hours. 

2.  R     Hydrastininse  hydrochloridi,  gr.  xlv         3.0 

Aquae  destillatse,  iiss  10.0 

M.     Sig. — Fifteen  to  thirty  drops  several  times  daily. 

3.  R     Ergotini,  gr.  xxx  2.0 

Aquae  destillatae,  ii  S.O 

M.     Sig. — Fifteen  to  thirty  drops  several  times  daily. 

The  further  treatment  of  acute  ulcer  should  be  the  same 
as  that  of  chronic  ulcer  of  the  stomach. 

CLINICAL    CASES 
1.  Chlorotic  Ulcer 

Case  1. — Louise  L.,  19  years  old,  had  suffered  from  violent  gnawing, 
boring  and  burning  epigastralgia,  which  radiated  to  the  back,  a  half -horn- 
after  eating  solids.    The  pain  continued  for  about  one  houi-.    It  did  not  occur 


l!26  DISEASES  OF  THE  DIGESTIVE  C.\NAL 

after  taking  liquids.  Lying  on  the  left  side  increased  the  pain,  while  the 
right-side  position  lessened  it.  There  was  a  point  in  the  epigastrium  exces- 
sively sensitive  to  pressure.  The  patient  was  chlorotic.  The  appetite  was 
good,  but  the  patient  was  afraid  to  eat  on  account  of  the  resulting  pain. 

Treatment  with  Leube's  ulcer-diet  and  bicarbonate  of  soda  produced 
a  permanent  cure. 

Case  2. — Elsie  G.,  a  servant,  32  years  old,  had  been  chlorotic  for  the 
past  four  or  five  years.  During  this  time  she  had  periodical  attacks  of 
crampy,  colic-like  i^ain  in  the  epigastrium.  For  about  fom*  weeks  the  patient 
had  suffered  from  epigastralgia,  which  radiated  to  the  left  shoulder.  The 
attacks  of  pain  occurred  one  hour  after  the  mid-day  and  evening  meals. 
She  had  a  good  appetite.  Physical  examination  revealed  points  of  excessive 
tenderness  below  the  xiphoid  process  and  posteriorly  to  the  left  of  the  ninth 
dorsal   vertebra. 

2.  Climacteric  Gastric  Ulcer 

Case  1. — Augusta  P.,  a  widow  49  years  old,  soon  after  the  cessation  of 
menstruation,  began  to  suffer  from  hsematemesis,  meltena,  and  regularly 
occurring  epigastralgia  one  hour  after  a  meal,  especially  of  solids.  Painful 
pressure-points  anteriorly  and  posteriorly.    Total  acidity,  88. 

Case  2. — Adeline  K.,  a  laboring  woman,  51  j^ears  old,  had  passed 
the  menopause  eight  years  previous,  since  which  time  she  had  suffered 
from  epigastralgia  one  hour  after  eating;  had  had  frequent  vomiting,  and 
one  attack  of  hipmatemesis.    Total  acidity,  102. 

Case  3. — Henrietta  S.,  a  cook  .50  years  old,  who,  previous  to  twenty 
years  ago,  had  suffered  from  chlorosis  and  "stomach-cramps,"  but  had 
remained  healthy  until  the  menopause.  Five  months  later,  the  patient  had 
experienced  typical  attacks  of  epigastralgia.  Upon  one  occasion  she  vomited 
blood  until  she  became  unconscious.  Meliaena  followed.  There  was  no 
hyperchlorhydria. 

3.  Pressure  Ulcer,  or  Ulcera  Decubitalia 

Case  1. — August  K.,  a  basket-maker,  52  years  old,  had  suffered  from 
epigastralgia  two  or  three  hours  after  the  principal  meal  of  the  day,  for  the 
past  two  or  three  years.  Upon  one  occasion  there  was  melsena  followed  by 
unconsciousness.  The  attacks  of  epigastralgia  were  reheved  by  sodium 
bicarbonate  and  warm  drinks.  For  several  years,  the  patient's  occupation 
had  demanded  that  he  sit  in  a  bent  position,  with  heavy  pressure  exerted 
against  the  epigastric  region.    The  total  acidity  was  90. 

Cure  resulted  from  rest  in  bed,  the  ulcer-diet,  and  the  use  of  bicarbonate 
of  soda  and  milk  of  almonds. 

Case  2. — Richard  S.,  a  shoemaker,  52  years  old,  had  in  his  occupation 
subjected  the  epigastrium  to  heavy  pressure  ever  since  he  was  a  young  man. 
Eleven  years  previous  to  this  time,  the  patient  began  to  suffer  from  his 


DISEASES  OF  THE  STOMACH  127 

stomach.  The  first  symptoms  were  epigastralgia  and  hscmatemesis.  He 
resumed  his  work  and  there  was  temporary  improvement.  One  year  ago, 
he  began  to  suffer  from  gnawing,  cramp-Hke  pains  in  the  epigastrium  four 
hours  after  meals,  which  were  reheved  by  hquids.  The  appetite  was  good. 
He  was  unable  to  have  rest  during  the  treatment. 

The  patient  was  put  on  an  ulcer-diet  and  was  given  from  two  to  three 
tablespoonfuls  of  olive  oil  before  meals.  There  was  an  immediate  improve- 
ment, and  he  did  not  suffer  from  acid  eructations  during  the  night.  Eight 
days  after  commencing  the  oil-treatment,  epigastralgia  had  ceased,  in  spite 
of  the  fact  that  the  patient  had  continued  his  occupation,  After  errors  in 
diet  and  after  having  given  up  the  use  of  the  oil,  on  account  of  the  hot 
weather,  there  was  a  return  of  the  ulcer-symptoms,  which  again  immediately 
disappeared  after  the  re-establishment  of  the  oil-treatment.* 

4.  Ulcers  and  Erosions  Following  Acid  Gastritis 

Case  1. — Ijeopold  B.,  a  merchant,  35  years  old,  gave  a  history  of 
excesses  in  eating,  smoking,  and  the  use  of  alcohol.  He  had  a  good  appetite 
and  regular  bowel-movements.  For  thirteen  months  he  had  suffered  from 
violent  attacks  of  epigastralgia  one  hour  after  light  meals,  and  two  to  three 
hours  after  heavy  meals,  which  were  always  immediately  controlled  by 
drinking  warm  milk.  No  improvement  followed  treatment  with  Carlsbad 
salts,  belladonna  and  antacids.    Total  acidity  of  the  test-breakfast  was  125. 

The  oil-treatment  was  then  instituted,  the  patient  taking  one-half 
wineglassful  in  the  morning,  and  a  tablespoonful  before  luncheon  and 
dinner.  Following  this,  there  was  immediate  relief.  The  patient  was  free 
from  pain  for  six  weeks,  when  there  was  a  return  of  the  symptoms  after  a 
meal  containing  Irish  stew  and  griddle-cakes.  After  beginning  the  oil- 
cure  again,  the  symptoms  disappeared.  The  after-cure  was  carried  out  at 
Carlsbad. 

Appendix 

Erosions  and  Fissures  of  the  Pylorus. — As  has 
already  been  mentioned,  erosions  and  fissures  may  occur  in 
the  mucous  membrane  of  the  stomach,  just  as  in  the  mouth, 
lips,  nose,  cardia,  and  anus,  which  present  clinical  symptoms 
very  similar  to  those  of  ulcer.  These  are  not  merely  hypo- 
thetically  present,  but  may  be  anatomically  demonstrated. 
They  are  located  chiefly  in  the  pars  jjylorica,  or  directly  within 
the  circumference  of  the  pylorus.  Proportionate  to  their  min- 
uteness, they  have  a  correspondingly  greater  tendency  to  heal 

*  I  could  tabulate  a  long  list  of  ulcer-cases  among  shoemakers,  locksmiths, 
basket-makers,  masons,  etc. 


128  DISEASES  OF  THE  DIGESTIVE  CANAL 

than  ulcers  of  the  stomach.  Surgeons,  especiall}',  have  demon- 
strated that  erosions  of  the  pylorus  are  frecjuentl}'  the  causes 
of  {ndorie  spasm,  with  secondary  dilatation  of  the  stomach. 

Etiology. — Fissures  and  erosions  of  the  gastric  mucosa 
are  caused  by  the  same  factors  as  ulcers:  on  the  one  hand, 
chlorosis  and  circulatory  disturbances;  on  the  other,  mechan- 
ical factors, — such  as  pressure  exerted  from  without,  and 
thermal  influences.  They  occur,  not  infrequently,  as  compli- 
cations of  acute  infectious  fevers,  and  they  are  especially 
freciuont  in  chronic  acid  gastritis  caused  by  excesses  in  eating, 
drinking,  and  smoking.     (See  above.) 

Symptoms. — The  most  important  symptom  of  erosions 
and  fissures  is  a  burning,  drawing,  and  often  cramp-like  pain, 
which  is  felt  some  little  time  after  eating.  Patients,  as  a  rule, 
experience  relief  immediately  after  the  introduction  of  food 
into  the  stomach,  or  there  may  be  a  complete  disappearance 
of  the  pain  until  from  one  to  three  hours  after  the  meal,  at 
which  time  gnawing,  tormenting,  burning  pains  recommence 
in  the  epigastrium. 

There  is  extreme  sensitiveness  to  pressure,  especially  in 
smokers,  which  is  frequently  so  intense  as  to  result  in  actual 
parox3'sms  of  colic,  which  are  not  relieved  until  the  patient 
vomits,  either  naturally  or  artificially,  or  unless  he  takes  milk 
or  an  alkali  to  neutralize  the  excessive  acidity  of  the  stomach. 

While  in  ulcer,  pain  occurs,  as  a  rule,  only  after  eating 
sohds,  the  symptoms  of  erosion  arise  some  little  time  after  foods 
of  any  kind,  even  liquids,  have  entered  the  stomach.  Pain  is 
especially  likely  to  appear  after  the  enjoyment  of  a  heavy  cigar, 
or  cold  drinks  such  as  beer  and  wine.  Cases  which  have  been 
cured  relapse  very  frequently  through  just  such  errors. 

The  physician  may  assume  the  location  of  the  patho- 
logical lesions  to  be  extra-pyloric  when  the  epigastralgia  is 
only  of  a  burning  character.  If,  on  the  other  hand,  the  attacks 
are  of  a  cramp-like  nature,  the  location  of  the  affection  is 
usually  in  the  pylorus. 

The  eructation  of  acid  fluids  several  hours  after  eating, 
at  the  time  when  the  stomach  should  be  quite  empty, — ^there- 


DISEASES  OF  THE  STOMACH  129 

fore  late  in  the  afternoon  or  at  night, — is  a  frequent  symp- 
tom of  erosion.     All  such  patients  suffer  from  pyrosis. 

Diagnosis. — The  clinical  differentiation  between  ulcer 
and  erosions  of  the  stomach  is  often  very  difficult  and  some- 
times impossible.  It  is  made  only  ex  juvantihus.  Erosion  of 
the  stomach  may  be  assumed,  as  a  rule,  if  pain  occurs  several 
hours  after  eating,  and  is  relieved  by  introducing  any  kind  of 
food  into  the  stomach,  even  a  piece  of  bread.  This  does  not 
occur  in  actual  ulceration  of  the  stomach. 

The  estimation  of  the  total  acidity  offers  no  criterion  by 
which  erosion  may  be  separated  from  ulcer,  since  in  the  former 
the  secretion  is  almost  always  above  normal.  The  increased 
acidity  is  caused  by  two  factors:  In  the  first  place,  from  the 
irritation  of  the  glandular  structures  of  the  stomach  caused 
by  food  stasis,  resulting  from  spasm  of  the  pylorus,  two  or 
three  hours  after  meals;  and  secondly,  the  hyperchlorhydria 
occurring  in  acid  gastritis,  which  may  precede  the  erosion  or 
be  simultaneous  with  it,  as  the  result  of  the  inflammatory 
process  of  the  mucous  membrane. 

Hemorrhages  also  occur  in  erosions  of  the  stomach,  just 
as  in  ulcer,  and  may  lead  to  a  fatal  termination.  Many  cases 
have  been  reported  in  the  literature  where  erosions  of  the 
gastric  mucous  membrane  were  scarcely  demonstrable,  and 
yet  were  the  cause  of  fatal  hsematemesis. 

Complications. — When  the  erosion  is  situated  directly  in 
the  pylorus,  and  causes  pyloric  spasm,  hypersecretion  and 
dilatation  of  the  stomach  will  result,  for  the  same  reasons  as 
in  ulcer  of  the  pylorus. 

Although  these  comphcations  are  caused  more  frequently 
by  cicatricial  stenosis  of  the  pylorus,  we  shall  see  below 
that  dilatation  occurring  as  a  result  of  pylorospasm  is  by  no 
means  rare. 

Scar-formation  and  perforation  never  result  from  ero- 
sions or  fissures  of  the  stomach,  and  there  is  not  the  same 
tendency  toward  malignant  degeneration  as  in  ulcer. 

Treatment. — The  treatment  is  etiological  and  symp- 
tomatic. 

9 


130  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  etiological  treatment  deals  with  the  removal  of  the 
factors  which  have  caused  the  disease,  especially  smoking, 
cold  drinks,  and  excesses  in  eating,  particularly  meat.  Com- 
pression of  the  epigastrium  should  be  avoided,  such  as  is 
caused  by  wearing  tight  clothing,  abdominal  bands,  or  any 
factor  through  which  pressure  of  hard  objects  is  brought  to 
bear  against  the  epigastrium,  as  occurs  in  various  occupations. 

Chlorotic  girls  demand,  first  of  all,  treatment  of  chlorosis, 
such  as  could  be  obtained  by  a  stay  at  a  chalybeate  spring, 
such  as  Flinsberg,  Pyrmont,  Schlangenbad,  etc. 

Patients  who  suffer  from  erosions  and  fissures  caused  by 
acid  gastritis,  should  be  sent  to  such  a  watering-place  as 
Carlsbad,  Neuenahr,  or  Vichy,  where  they  may  receive  the 
treatment  specifically  suitable  to  their  condition;  or  they  may 
use  the  bottled  water  or  the  artificial  salts  in  their  homes. 

In  persistent  cases  of  erosions  or  fissures,  the  mineral  water 
should  be  used  uninterruptedly  for  from  three  to  six  months. 

For  further  details  concerning  these  cases,  the  reader  is 
referred  to  the  chapter  on  Acid  Gastritis. 

Erosions  or  fissures  which  are  not  caused  by  acid  gastritis 
should  be  treated  as  light  cases  of  ulcer. 

The  treatment  may  be  ambulatory,  consisting  of  a  bland, 
non-irritating  diet  and  the  use  of  antacids  and  olive  oil. 
For  this  purpose,  the  physician  should  prescribe  one-half  to 
one  wineglassful  of  olive  oil  at  a  temperature  of  30°  R.  [100°  F.] 
early  in  the  morning  before  breakfast,  and  a  tablespoonful 
before  luncheon  and  dinner.  In  all  cases  suffering  from  epi- 
gastralgia  during  the  night,  the  oil  should  also  be  given  in 
the  evening  before  retiring. 

The  clinical  records  of  patients  given  at  the  end  of  the 
chapter  demonstrate  that  in  persistent  epigastralgia,  when 
all  other  treatments  have  proved  ineffectual,  the  use  of  olive 
oil  has  resulted  in  relief  and  final  recovery. 

The  use  of  oil  would  be  less  applicable  in  those  cases  of 
erosions  in  which  the  lesion  was  not  situated  at  the  pylorus  and 
in  which,  therefore,  the  patient  did  not  suffer  from  epigastralgia, 
but  only  from  the  burning  sensation  in  the  epigastrium. 


DISEASES  OF  THE  STOMACH  131 

For  those  who  have  a  repugnance  toward  the  use  of  the 
oil,  the  milk  of  almonds,  which  they  can  prepare  at  home, 
may  be  substituted  (see  page  124). 

The  symptomatic  treatment  of  erosions  and  fissures 
consists  in  the  administration  of  an  antacid  before  meals, 
such  as  bicarbonate  of  soda,  magnesium  salts,  etc.,  in  tea- 
spoonful  doses,  with  or  without  the  addition  of  the  extract  of 
belladonna. 

Bergmann's  or  Belloc's  mastication  tablets,  one  to  three 
after  eating,  are  also  helpful. 

Great  relief  is  obtained  from  the  symptoms  by  the  thor- 
ough mastication  of  hard  bread-crusts  after  meals,  whereby 
a  large  quantity  of  saliva  is  secreted  and  swallowed,  which 
tends  to  neutralize  the  excessive  acidity  of  the  gastric  juice. 

CLINICAL    CASES 

Case  1. — Mr.  S.,  a  business  man,  35  years  old,  had  suffered  periodically 
for  five  years  from  pressure  and  burning  in  the  epigastrium  after  eating. 
Very  late  in  the  afternoon,  he  had  cramp-Hke  pains.  The  stools  were  regular. 
He  had  lost  14  pounds  in  weight.  The  patient  traced  his  affection  back  to 
a  period  when  he  indulged  in  "over-nourishment."  There  had  been  fre- 
quent vomiting  of  acid  liquids  and  food.  The  physical  examination  was 
negative.  The  test-breakfast,  upon  removal,  contained  much  fluid,  and  its 
total  acidity  was  80.  Remnants  of  ham  which  had  been  eaten  the  evening 
before  were  found. 

The  treatment  consisted  in  the  ulcer-diet,  the  use  of  milk  of  almonds 
three  times  daily  before  eating,  and  belladonna  combined  with  an  alkaU 
three  times  a  day,  two  hours  before  eating.  It  was  impossible  for  the  patient 
to  go  to  bed  for  treatment.  Ten  days  later  he  returned  to  the  clinic,  having 
suffered  no  pain  and  having  gained  one  and  one-half  pounds  in  weight. 
After  one  month  of  treatment,  he  had  gained  three  pounds,  and  had  been 
entirely  free  from  pain,  except  on  one  occasion  when,  after  partaking  of 
cakes  and  coffee,  he  had  suffered  from  a  burning  sensation  in  the  stomach. 
He  had  not  been  using  any  medication.  The  use  of  milk  of  almonds  was 
advised,  and  later  on  Vichy  water.  Six  months  later  the  patient  had  gained 
six  pounds  in  weight. 

Clinical  Diagnosis. — Acid  gastritis,  with  erosions  of  the  fundus  and 
pylorus.  Hj^perchlorhydria,  with  occasional  spasm  of  the  pylorus,  which 
led  to  temporary  retention  of  food. 

Case  2. — Alphonse  M.,  a  merchant,  38  years  old,  was  a  hea\^  smoker, 
eater,  and  drinker.    He  was  obese.    For  four  or  five  years  the  patient  had 


132  DISEASES  OF  THE  DIGESTIVE  CANAL 

suffered  from  severe  pjTOsis  and  burning  pains  in  the  stomach.  For  two 
or  three  years,  he  had  had  cramp-Hke  pains  in  the  epigastrium  and  behind 
the  sternum  quite  frequently. 

Treatment. — Oil  was  prescribed  in  the  morning  before  breakfast, 
and  mastication  tablets  and  an  alkali  after  meals.  Four  weeks  later,  the 
patient  reported  that  he  still  had  occasional  cramp-like  pains.  Then  Vichy 
water,  belladonna  in  pill  form,  and  later  on,  milk  of  almonds,  were  prescribed, 
which  caused  the  disappearance  of  the  symptoms.  On  account  of  frequent 
errors  in  diet,  the  patient  still  suffered  occasionally  from  heartburn. 

Case  3. — Mr.  R.,  a  merchant,  27  years  old,  was  a  heavy  smoker. 
The  patient  had  suffered  periodically  for  a  year  and  a  half,  from  cramp- 
like pains  in  the  stomach,  two  or  three  hours  after  meals,  which  were  alwaA^s 
relie\'ed  by  eating  again.    He  had  always  had  a  hearty  appetite. 

Treatment. — Half  a  wineglassful  of  olive  oil  was  prescribed  in  the 
morning  and  a  cup  of  milk  of  almonds  at  noon  and  in  the  evening  before 
eating.  Belladonna,  combined  with  an  alkali,  was  given  t'wice  daily  after 
meals.  The  patient  was  immediately  free  from  discomfort  in  the 
stomach.  The  after-treatment  consisted  in  the  use  of  Vichy  water. 
Permanent  cure  resulted. 

Case  4. — Mr.  M.,  a  business  man,  43  years  old,  was  a  very  heavy 
smoker,  using  twelve  to  fourteen  cigars  daily;  a  heavy  eater,  and  obese. 
For  four  or  five  years  the  patient  had  suffered  from  burning  in  the  epigas- 
trium after  heavy  meals.  Temporary  improvement  had  followed  two  mineral- 
water  "cures"  at  Carlsbad.    The  physical  examination  was  negative. 

The  patient  was  given  a  bland,  non-irritating  diet,  Vichy  water,  and  the 
mastication  tablets.  He  remained  free  from  discomfort  unless  he  indulged 
in  smoking,  the  use  of  cold  beer,  greasy  foods,  heavy  meats, — ^goose,  etc., — 
which,  in  every  instance,  caused  a  return  of  the  burning  pain  in  the  stomach. 

After  another  course  of  treatment  at  Carlsbad,  and  with  a  continued 
careful  mode  of  living,  the  patient  remained  well. 

Case  5. — Inspector  K.,  39  years  old,  and  very  obese,  in  his  history 
disclosed  excesses  in  beer-drinking,  eating,  and  smoking.  For  several 
weeks,  the  patient  had  suffered  from  burning  and  pressure  in  the  epigastrium 
and  oesophagus  two  or  three  hours  after  eating.  Dn-ectly  after  meals,  he 
would  be  free  from  discomfort.  Total  acidity  of  the  test-breakfast,  112. 
jMeteorism.  Thirty-two  c.c.  of  gastric  juice,  with  a  total  acidity  of  80,  were 
obtained  from  the  fasting  stomach. 

A  complete  clinical  cure  was  effected  by  the  use  of  Carlsbad  salts, 
two  or  three  teaspoonfuls  daily  before  eating;  and  by  giving  up  beer,  tobacco, 
and  heavy,  greasy  foods. 

Clinical  Diagnosis. — Acid  gastritis,  with  erosions  of  the  mucosa  (burn- 
ing pains),  not  located  at  the  pylorus,  since  epigastralgia  was  not  a  symptom ; 
and  also  hypersecretion  caused  by  the  irritation  of  the  digestive  glands. 


DISEASES  OF  THE  STOMACH  133 

CLOSING    REMARKS 

I  am  very  well  aware  that  often  an  exact  diagnosis  of 
erosions  of  the  stomach  cannot  be  made,  beyond  a  probability. 

The  existence  of  erosions  and  fissures  of  the  pylorus  is 
denied  by  many,  in  spite  of  which,  for  practical  purposes,  I 
should  like  to  maintain  the  above-mentioned  facts.  At  all 
events,  I  do  not  think  that  simple  hyperchlorhydria,  as  such, 
in  the  absence  of  an  anatomical  lesion, — for  instance,  a  gastric 
neurosis, — produces  burning  and  cramp-like  pains  in  the  epi- 
gastrium. When  these  symptoms  are  present,  an  organic 
affection  of  the  stomach  or  of  a  neighboring  organ  should 
always  be  thought  of,  and  the  therapeutic  measures  directed 
accordingly. 

Carcinoma  of  the  Stomach 

General  Remarks. — The  etiology,  the  pathological  anat- 
omy, the  occurrence,  frequency,  hereditary  influences,  age- 
limits,  etc.,  of  cancer  of  the  stomach,  will  not  be  discussed 
here.  We  shall  consider  only  the  significance  and  the  relation- 
ship of  gastric  ulcer  and  traumata  to  gastric  carcinoma. 

Malignant  degeneration  of  chronic  ulcer  is  quite  fre- 
quent, especially  in  patients  of  advanced  years.  Beside  the 
ulcer,  the  cicatricial  formation  of  ulcer  frequently  gives  rise 
to  the  development  of  cancer.  The  well-known  carcinoma- 
tous ulcer,  the  symptomatology  of  which  will  be  considered 
in  detail  later  on,  begins  in  this  way. 

Cancer  attacks  individuals  who  have  not  previously  suf- 
fered from  stomach  trouble  or,  as  has  already  been  mentioned, 
persons  who  have  previously  had  ulcer.  As  a  rule,  patients 
suffering  from  other  chronic  stomach-affections  are  exempt. 

Concerning  carcinomata,  it  may  be  said  with  certainty 
that  acute,  as  well  as  chronic,  injury  exerts  a  decided  influence 
in  the  development  of  gastric  carcinoma.  As  a  rule,  the 
evolution  of  such  a  process  is  as  follows:  As  a  result  of  an 
injury  to  the  stomach,  a  pressure-necrosis  with  an  ulceration 
of  the  mucosa  occurs,  which  later  undergoes  a  carcinomatous 
degeneration. 


134 


DISEASES  OF  THE  DIGESTIVE  CANAL 


I  emphasize  this,  for  the  reason  that  frequently  [in 
Germany]  the  expert  testimony  of  the  physician  must  estab- 
hsh  whether  a  carcinoma  of  the  stomach  is  the  result  of 
traumatism  or  not. 

It  is  possible  to  trace  the  origin  of  a  cancer  to  trauma,  if  the  first 
symptoms  of  malignant  disease  of  the  stomach  occur  within  a  year  or  a 
year  and  a  half  after  injury, — the  patient  having  previously  had  good 

Fig.  2fi. 


Carcinomatous  degeneration  of  an  ulcer  of  the  pylorus.     [Courtesy  of  Dr.  Stanley  P.  Black, 
of  the  Hendry.K  Laboratory,  University  of  Southern  California.] 

digestion,  and  the  injury  having  affected  the  region  of  the  stomach  itself ; 
in  such  a  case,  the  physician  may  often  state  that  it  is  his  conviction 
that  trauma  has  been  an  etiological  factor  in  the  production  of  the 
cancer.  On  the  other  hand,  it  would  not  be  possible  to  associate  an 
injury  received  several  years  previously,  especially  to  some  other  part  of 
the  body,  with  a  subsequent  carcinoma  of  the  stomach. 

General  Symptomatology  and  Diagnosis. — Cancer  some- 
times develops  acutely,  but  as  a  rule,  almost  always  slowly 
and  without  warning,  beginning  with  loss  of  appetite,  repug- 
nance  toward    meats,    feeling   of   nausea,    lassitude,   lack   of 


DISEASES  OF  THE  STOMACH  135 

desire    to    work,    increasing    weakness,    emaciation,    anaemia, 
and  cachexia. 

The  tongue  is  always  coated,  proportionate  to  the  poor- 
ness of  mastication  and  the  diminished  amount  of  food  eaten. 
Later  on,  pressure  in  the  epigastrium  occurs,  especially  after 
eating  hard  foods,  just  as  in  chronic  gastritis.  And  still  later 
on  occur  cramp-like  pains,  depending  upon  whether  the  car- 
cinomatous lesion  is  located  at  the  pylorus,  or  not. 

In  these  cases,  there  is  vomiting, — the  vomitus,  on  ac- 
count of  the  mixture  of  the  food  with  blood,  presenting  a 
black-brownish,  ''coffee-ground"  appearance. 

In  the  terminal  stage  of  cancer  of  the  stomach, — when 
cachexia  is  marked, — fever,  hydrsemia,  and  with  these  albu- 
minuria and  oedema  of  the  ankles  occur. 

The  physician  must  always  keep  in  mind  the  fact,  how- 
ever, that  in  individual  cases  the  appetite  may  be  retained  for 
a  long  time;  and  especially  that  the  patient  may  not  experi- 
ence a  repugnance  toward  meat;  and  above  all,  that  fre- 
quently in  carcinoma,  vomiting  is  not  a  symptom.  These 
are  the  cases  in  which  neither  the  inlet  nor  the  outlet  of  the 
stomach  is  involved.  Likewise,  haematemesis  or  melsena 
may  never  occur. 

When  the  cancer  involves  the  pylorus,  symptoms  of 
pyloric  obstruction,  with  stagnation  of  the  stomach-contents, 
naturally  occur.  Whether  gastrectasis  follows  malignant 
obstruction  of  the  pylorus  or  not,  depends  largely  upon  the 
appetite.  Patients  with  good  appetites,  who  eat  freely  and 
vomit  little,  are  the  ones  most  likely  to  suffer  from  secondary 
dilatation  of  the  stomach;  while,  on  the  other  hand,  there  often 
occurs  a  contraction  of  the  entire  stomach  in  those  patients  who 
eat  little,  and  especially  if  the  food  is  vomited.  Atrophy  of  the 
stomach  is  especially  frequent  in  carcinoma  of  the  cardia. 

The  secretion  of  gastric  juice  in  cancer  of  the  stomach 
is,  as  a  rule,  totally  lost,  so  that  from  the  clinical  standpoint  the 
findings  are  exactly  those  of  atrophic  gastritis.  Hydrochloric 
acid,  rennin,  and  pepsin  are  almost,  or  completely,  absent. 
The  test-breakfast  furnishes  the  picture  of  achylia  gastrica. 


136  DISEASES  OF  THE  DIGESTIVE  CANAL 

An  exception  to  these  findings  occurs  in  carcinoma  result- 
ing from  malignant  degeneration  of  an  ulcer,  in  which  free 
hydrochloric  acid  ma}^  be  demonstrable  up  to  the  end  of  life. 

Lactic  acid  is  found  only  in  those  cases  of  cancer  in  which 
there  is  stagnation  of  the  stomach-contents,  resulting  from 
carcinoma  of  the  pjdorus,  as  soon  as  the  atrophy  of  the  mucous 
membrane  has  progressed  far  enough  so  that  measurable 
amounts  of  hydrochloric  acid  are  no  longer  secreted. 

Uft'elmann's  [or  Strauss's]  lactic  acid  tests  are,  therefore, 
not  positive  in  all  cases  of  cancer  of  the  stomach,  because 
not  all  such  give  rise  to  food-stagnation;  and  besides,  the 
motility  of  the  stomach  may  be  normal  if  the  cancer  docs  not 
involve  the  pylorus. 

The  Boas-Ewald  test-meal  has  a  total  acidity  of  from 
6  to  8  in  cases  of  carcinoma  unassociated  with  food-stasis. 
But  if  there  is  stagnation  of  food,  the  total  acidity  is  higher, 
for  the  reason  that  the  fermentation  acids, — especially  lactic 
and  acetic  acids, — are  also  present. 

The  bowel-movements  are  usually  sluggish,  correspond- 
ing to  the  lessened  consumption  of  food.  Diarrhcea  occurs 
only  if  a  complication  develops,  such  as  a  fistula  between  the 
stomach  and  the  colon. 

Diagnosis. — In  the  beginning  of  the  affection,  diagnosis 
is  very  difficult;  and  in  many  cases,  only  a  probable  diagnosis 
can  be  made.  Naturally,  the  diagnosis  becomes  quite  posi- 
tive if  a  large,  irregular  tumor  can  be  palpated  in  the  epi- 
gastrium. There  are,  however,  many  cases  of  cancer  in  which 
no  tumor  can  be  felt  during  the  entire  life  of  the  patient. 
This  occurs  most  frequently  in  men  who  have  normal  habitus, 
with  a  wide  costal  angle  and  firm  abdominal  walls.  In  these 
cases,  if  the  tumor  is  not  situated  in  the  left  hypochondrium 
behind  the  ribs,  it  will  usually  be  hidden  behind  the  left  lobe  of 
the  liver  and  so  closely  adherent  to  the  latter  that  it  cannot  pro- 
ject below  the  fiver-edge  far  enough  to  be  subject  to  palpation. 

In  case  the  physician  is  able  to  palpate  a  tumor,  he  must, 
first  of  all,  determine  whether  it  is  hard,  knotty,  and  irregular, 
or  whether  it  is  smooth,  and  if  he  can  outline  its  borders. 


DISEASES  OF  THE  STOMACH  137 

Benign  tumors  of  the  epigastrium, — such  as  cysts,  dis- 
tended gall-bladders,  and  hypertrophy  of  the  pylorus, — are, 
as  a  rule,  smooth  and  not  very  hard. 

It  is  important,  above  all,  to  determine  the  respiratory 
movability  of  the  tumor;  whether  it  is  fixed,  i.e.,  whether  it 
rises  and  falls  during  respiration.  In  case  it  rises  during 
expiration,  it  is  very  probable  that  the  tumor  is  adherent, 
especially  to  the  liver.  Tumors  which  are  limited  to  the  stom- 
ach are  usually  stationary.  In  the  latter  cases,  surgery  offers 
better  chances  for  cure  than  in  the  former;  and  the  physician 
should,  therefore,  advise  early  operative  procedures. 

Close  attention  should,  of  course,  be  given  to  the  degree 
of  sensitiveness  to  pressure  of  such  tumors,  and  the  physician 
must  never  neglect  to  examine  closely  the  liver  and  the  regional 
lymph  glands  of  the  groin  and  clavicle  for  possible  metastases. 

Differential  Piagnosis.— Tumors  in  the  epigastrium,  in 
the  majority  of  cases,  are  carcinomatous.  There  are,  how- 
ever, also  benign  tumors  of  the  stomach,  pancreas,  and  liver, 
such  as  cysts,  polyps,  gummata,  concretions,  and  hydatids; 
and  besides  these,  the  physician  must  always  keep  in  mind 
the  possible  existence  of  malignant  tumors  of  the  neighbor- 
ing organs,  such  as  the  pancreas,  colon,  liver,  and  the  retro- 
peritoneal lymph  glands,  although  these,  on  the  whole,  are 
quite  rare. 

DIAGNOSIS    OF     CARCINOMA    OF    THE    STOMACH    BEFORE    IT    IS 
POSSIBLE    TO    LOCALIZE    THE    TUMOR    BY    PALPATION 

Carcinomata  of  the  stomach,  from  the  standpoint  of 
practical  diagnosis,  are  divided  into  three  large  groups: 
pyloric,  cardiac,  and  extra-ostial. 

Each  of  these  groups  presents  such  characteristic  signs  and 
symptoms  that  their  differentiation  is  proportionately  easy. 

Cancer  usually  has  its  origin  in  some  point  of  the  lesser 
curvature,  which  agrees  with  the  hypothesis  of  the  mechanical 
theory  of  the  etiology  of  cancer,  because  the  lesser  curvature 
is  most  exposed  to  mechanical,  thermal,  and  chemical  injuries 
from  the  swallowed  ingesta. 


138  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  accompain'ing  illustration  (Fig.  27)  explains  the 
developmcjit  and  progress  of  carcinoma  of  the  stomach. 

Assuming  that  the  tumor  begins  at  a  point  in  the  lesser 
curvature,  the  proliferation  of  the  cancer  may  extend  in  three 
different  directions:  first,  toward  the  pylorus,  which  happens 
most  frequently;  second,  toward  the  anterior  or  the  posterior 
wall  of  the  stomach;  third,  toward  the  cardia,  which  is  rela- 
tivel}'  the  most  infrequent  of  the  three.     It  is  self-evident 

Fig.  27. 


Diagram  showing  the  development  and  progress  of  cancer  of  the  stomach. 

that  there  are  many  cases  of  carcinomata  in  which  the  lesion 
involves,  primarily,  the  pylorus,  its  neighborhood,  or  the  cardia. 
It  is  very  easy  to  point  out  how  these  forms  develop 
quite  different  and  characteristic  symptoms. 

1.   The    Tumor   Beginning   at   or    Proliferating   toward 
the  Pylorus. 

In  these  cases,  stagnation  of  the  stomach-contents  is  the 
dominating  feature  of  the  clinical  picture. 

Food-stasis  manifests  itself  by  the  vomiting  of  large 
quantities  of. food,  and  especiall}^  of  food  which  the  patient 
has  eaten  on  preceding  days.  For  instance,  when  the  patient 
vomits  such  food  as  rice,  fruit,  or  remnants  of  vegetables, 
which  he  states  he  has  eaten  several  days  previously,  the 
diagnosis  of  stasis,  and  therefore  of  narrowing  of  the  stomach 
outlet,  may  be  made.     The  diagnosis  of  stasis  will  be  more 


DISEASES  OF  THE  STOMACH  139 

certain  if  the  physician  is  able,  by  the  use  of  the  stomach- 
tube,  to  obtain  food-remnants  from  the  stomach  of  the  patient 
early  in  the  morning  before  breakfast. 

a.  Stagnating  Foods  which  Contain  Free  Hydrochloric 
Acid. — In  these  cases,  there  exists  either  a  benign  obstruction 
or  an  obstruction  caused  by  a  carcinomatous  degeneration 
of  chronic  ulcer.  Sometimes  the  differential  diagnosis  between 
these  is  only  possible  by  long  clinical  observation.  As  a  rule, 
in  obstructions  due  to  carcinomatous  ulcer,  there  is  a  lessened 
or  rapid  diminution  in  the  amount  of  hydrochloric  acid 
secreted;  while  in  benign  stenosis,  there  is  an  increase  in  the 
amount  of  hydrochloric  acid. 

In  both  conditions,  a  microscopical  examination  will 
show  the  presence  of  sarcinse  and  yeast-cells. 

In  primary  carcinoma  of  the  pylorus,  hydrochloric  acid 
will  also  be  found  in  the  stagnating  contents  of  the  stomach, 

b.  Stagnating  Stomach-Contents  which  Contain  Lactic  Acid, 
hut  no  Free  Hydrochloric  Acid. — In  these  cases  congo  paper 
shows  only  a  weak,  dark  coloration,  but  never  the  blue  tone 
given  by  free  hydrochloric  acid.  The  lactic-acid  test  is 
positive    (see   above). 

Microscopically,  sarcinae  are  absent,  but  the  field  of  the 
microscope  is  overrun  with  the  long,  thread-like  Oppler- 
Boas  bacilli. 

In  rare  cases  both  bacilli  and  sarcinse  are  present. 

Stagnating  stomach-contents  containing  lactic  acid  are 
obtained  almost  exclusively  from  patients  suffering  from 
carcinoma  of  the  pylorus,  or  carcinoma  of  some  of  the  neigh- 
boring organs,  which,  from  pressure,  narrows  the  stomach- 
outlet.  An  exception  to  these  is  the  stenotic  gastritis  of 
Boas,  a  form  of  chronic  catarrh  of  the  stomach,  which  has 
already  been  discussed  in  the  chapter  on  Chronic  Gastritis. 
Stenotic  gastritis  is  extremely  rare,  and,  so  far  as  diagnosis  is 
concerned,  demands  little  consideration,  and  for  treatment 
scarcely  any,  because  this  form  of  gastritis,  just  as  carcinoma 
of  the  pylorus,  requires  resection,  or  gastro-enterostoni}^,  etc., 
if  the  life  of  the  patient  is  to  be  prolonged. 


140  DISEASES  OF  THE  DIGESTIVE  CANAL 

Summary. — If,  in  a  suspected  case,  a  tumor  is  palpable 
and  renuiants  of  old  food  are  obtained  from  the  fasting 
stomach,  the  ph^'sician  may  assume,  with  the  greatest  prob- 
ability, the  presence  of  carcinoma  of  the  pylorus  or  pars 
pylorica,  especiall}^  if  the  contents  of  the  stomach  show  either 
lactic-acid  fermentation,  as  in  primary  carcinoma,  or  con- 
siderable diminution  in  the  secretion  of  hydrochloric  acid, 
as  in  carcinomatous  ulcer. 

Such  cases  should  be,  as  earl}"  as  possible,  referred  to  the 
surgeon,  who,  after  opening  the  abdominal  cavity,  will  decide 
which  operation  or  procedure  is  indicated. 

II.   Carcinomata   Developing    Extra-ostially,   Producing    There- 
fore no  Symptoms  of  Stenosis  at  the  Pylorus  or  Cardia 

In  these  cases,  as  a  glance  at  the  diagram  will  show,  no 
obstruction  at  the  pylorus  exists,  therefore  there  is  an  absence 
of  symptoms  of  stasis  or  motor  insufficiency  of  the  stomach. 

The  findings  of  the  test-breakfast  can  scarcely  be  differen- 
tiated from  the  contents  obtained  from  the  stomach  in  atrophic 
gastritis.  In  both,  hydrochloric  acid,  rennin  and  pepsin  are 
nearly  or  completely  absent.     The  test-breakfast  is  achylous. 

The  microscopical  examination  of  the  material  obtained 
from  the  fasting  stomach  usually  gives,  however,  suggestive 
points  in  regard  to  the  lesion,  viz.,  the  presence  of  large 
numbers  of  red  and  white  blood-corpuscles;  sometimes  also 
of  amoeba,  infusoria  and  fetid  material,  besides  the  sputa, 
histological  constituents  of  the  mucous  membrane  of  the 
mouth  and  oesophagus,  such  as  epitheha,  etc. 

Therefore,  in  suspected  cases,  in  w^hich  there  have  been 
progressive  cachexia,  loss  of  appetite,  pressure  in  the  stomach, 
though  wdth  no  stagnation  of  the  stomach-contents,  and 
where  achylia  gastrica  is  present,  the  physician  should  examine 
the  contents  obtained  from  the  fasting  stomach  with  the 
greatest  care.  As  a  rule,  only  a  few  cubic  centimetres  will 
be  obtained  from  the  stomach  in  introducing  the  stomach- 
tube,  and  these  contents  should  be  blown  out  of  the  end  of 
the  stomach-tube  into  a  receptacle  for  examination. 


DISEASES  OF  THE  STOMACH  141 

Mistakes  arc  also  possible  here,  for  the  reason  that  blood- 
and  pus-corpuscles  also  occur  in  benign  atrophic  gastritis, 
though  not  in  so  great  numbers.  In  malignant  cases,  the  pus 
can  usually  be  seen  macroscopically. 

The  RhodankaHum  reaction  of  the  saliva  is  also  said  to 
be  absent  in  carcinoma  (see  page  96). 

According  to  Boas,  the  examination  of  the  faeces  for 
occult  blood  is  very  important  in  all  such  cases.  If  the  exam- 
iner finds  a  positive  test  for  occult  blood  in  the  feeces  of  a 
patient  with  achylia,  who  has  for  three  days  been  on  a  hsema- 
globin-free  diet,  it  is  in  the  highest  degree  probable  that  a 
latent  extra-ostial  carcinoma  of  the  stomach  exists.  In  the 
examination  for  occult  blood, — the  technic  of  which  is 
given  on  pages  41  and  252, — it  is  scarcely  necessary  to  mention 
that  it  is  essential  to  exclude  the  origin  of  the  blood  from 
hemorrhoids,  etc. 

III.  Carcinomata  Developing  at   the  Cardia  or  Prolifer- 
ating toward  It 

In  these  cases,  difficulty  in  swallowing  always  occurs, 
in  addition  to  the  general  symptoms  of  cancer. 

Upon  introducing  the  stomach-tube,  an  obstruction  is  en- 
countered about  40  cm.  from  the  incisors.  On  being  removed, 
the  tube  is  frequently  covered  with  blood  and  fetid  pus. 

In  these  cases,  stagnation  of  the  stomach-contents  and 
lactic-acicl  fermentation  are  absent,  for  the  same  reasons  as  in 
extra-ostial  carcinomata. 

Stasis  of  food  within  the  oesophagus  with  lactic-acid 
fermentation  may,  however,  occur. 

A  tumor  of  the  cardia  can  rarely  be  palpated,  because 
of  its  position  behind  the  liver  and  the  costal  cartilages. 

A  close  clinical  observation  of  all  these  symptoms  makes 
it  possible  for  us  to  follow,  accurately,  the  progress  and 
development  of  cancer  of  the  stomach,  even  in  those  cases 
in  which  we  are  unable  to  palpate  a  tumor. 

It  is  self-evident,  however,  that  there  will  always  be 
cases  in  which  the  symptoms  are  only  those  of  achylia  gastrica 


m 


DISEASES  OF  THE  DIGESTIVE  CANAL 


and  general  cachexia,  when  the  diagnosis  of  cancer  cannot  be 
established  bej^ond  a  certain  probability. 

With  the  application  of  these  diagnostic  i)rinciples,  we 
have  shown,  therefore,  that  even  in  cases  in  which  a  tumor  is 
not  pali)ablc  it  is  relatively  easy — first,  to  make  a  diagnosis 

Fig.  28. 


Cancer  of  the  cardia  producing  stenosis.    [Courtesy  of  Dr.  Stanley  P.  Black,  of  the  Hendryx 
Laboratory,  University  of  Southern  California.] 

of  gastric  cancer  as  such;  and  second,  to  determine  its  loca- 
tion, the  knowledge  of  which  is  always  essential  to  the  internist 
in  establishing  the  correct  indication  for  medical  treatment 
or  surgical  interference. 

If  the  tumor  is  palpable  in  the  epigastrium,  the  physician 
can  determine,  by  the  distention  of  the  stomach  with  gas  or 
air,  whether  it  belongs  to  the  anterior  or  the  posterior  wall  of 
the  stomach,  or  whether  it  lies  behind  the  stomach.     Tumors 


DISEASES  OF  THE  STOMACH  143 

of  the  anterior  wall  of  the  stomach  become  more  distinct  after 
distention,  while  those  of  the  posterior  wall  entirely  disappear. 
To  inflate  the  stomach,  the  physician  should  use,  by 
preference,  a  thin  stomach-tube  with  a  diameter  of  8  or  9 
millimetres,  with  an  ordinary  inflating  bulb.  Distention  of 
the  stomach  with  the  well-known  effervescent  powders  should 
be  avoided,  for  the  reason  that  the  carbon  dioxide  gas  gener- 
ates so  suddenly  and  violently  that  syncope  and  perforation 
of  the  stomach-wall  might  easily  occur. 

THE    CLINICAL    COURSE    OF    CANCER    OF    THE    STOMACH 

Carcinoma  of  the  stomach  generally  causes  death 
from  exhaustion  within  one  or  two  years.  Carcinoma  of  the 
pylorus  causes  a  fatal  termination  sooner,  on  account  of  the 
resulting  obstruction  at  the  pylorus,  which  prevents  the 
chyme  from  entering  the  intestine.  Emaciation  in  these 
cases  is,  therefore,  more  rapid,  and  death  naturally  occurs 
much  earlier.  Sudden  and  fatal  termination  may  also  result 
from  severe  hemorrhage. 

The  clinical  symptoms  of  some  cases  of  cancer  of  the 
stomach  are  so  latent,  and  so  few  of  a  localized  nature  appear, 
that  the  disease  closely  resembles  progressive  pernicious 
anaemia.  The  autopsy  findings  alone  will  establish  the 
diagnosis. 

COMPLICATIONS    OF    CANCER    OF    THE    STOMACH 

Apart  from  metastases  into  the  liver  and  the  regional 
lymph-glands,  and  adhesions  with  neighboring  organs,  which 
almost  invariably  occur  in  carcinoma  of  the  fundus  of  the 
stomach,  fistulse  sometimes  form  between  the  greater  curva- 
ture and  the  transverse  colon.  With  this  complication,  either 
feculant  vomiting  or  a  lienteric  diarrhoea  occurs.  The  forma- 
tion of  secondary  abscesses  in  the  peritoneum  with  external 
perforation  is  sometimes  observed,  as  well  as  subphrenic 
abscesses.  We  have  sufficiently  emphasized  the  fact  that 
secondary  dilatation  of  the  stomach  frequently  results  from 
cancer  of  the  pylorus. 


144  DISEASES  OF  THE  DIGESTIVE  CANAL 

TREATMENT  OF  CANCER  OF  THE  STOMACH 

a.  Internal  Treatment. — The  internal  therapy  of  carci- 
noma of  the  stomach  is  not  so  ineffective  as  might  ap})ear, 
considering  the  malignant  nature  of  the  affection.  Although 
we  are  not  in  a  position  in  any  sense  to  bring  about  a  cure  or 
to  lessen  its  progressive  tendency,  we  are,  nevertheless,  able 
at  the  present  time  to  remove  or  lessen  the  suffering  of  the 
patient  and  considerably  to  prolong  life  by  maintaining  the 
physical  strength  of  the  patient,  provided  his  financial  condi- 
tion permits  of  his  having  the  best  care  and  treatment. 

The  treatment  is  dietetic,  mechanical  and  medicinal, 
and  should  be  directed  entirely  according  to  the  location  of 
the  lesion. 

Dietetic  Treatment. — In  carcinoma  of  the  pylorus,  if  the 
resulting  stenosis  is  not  already  of  sufficient  severity  to 
demand  operation,  the  diet  must  be  adapted  to  the  degree  of 
obstruction,  in  order  to  prevent  the  patient  from  starvation. 
It  should,  therefore,  be  of  liquid  or  semi-solid  consistency, 
and  rich  in  liquid  fats.     (Butter,  cream  and  olive  oil.) 

In  carcinomata  not  involving  the  pyloric  region,  the 
treatment  will  not  differ  from  that  of  atrophic  gastritis. 

In  these  cases,  an  operation  is  generally  useless, — not 
only  useless,  but  a  surgical  error,  since  the  attempt  at  a  radical 
removal  of  the  cancer  is  usually  hopeless  in  such  conditions. 

When  the  motility  of  the  stomach  is  quite  normal,  excel- 
lent results  are  obtained  through  dietetic  measures,  the 
patient  still  being  able  to  enjoy  many  of  the  pleasures  of  the 
table.  An  increase  in  weight  of  from  10  to  20  pounds  by 
adherence  to  a  rational  diet  is  not  unusual,  even  after  a  posi- 
tive diagnosis  of  cancer  has  been  made.  I  have  seen  such  a 
result  in  several  cases.  For  instance,  a  recent  patient,  after  a 
few  months  of  treatment  and  a  rational  diet,  was  able  to 
indulge  in  such  pastimes  as  hunting.  Of  course,  such  improve- 
ment was  only  temporary,  continuing  at  the  very  longest  for 
from  six  to  nine  months,  when  the  progress  of  the  disease  and 
cachexia  again  took  place. 


9; 

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11 

DISEASES  OF  THE  STOMACH  145 

The  dietary  in  such  cases  shouhJ  be  directed  about  as 
follows : 

7:00  .\.M.      Milk  soup,   cooked  with  cream  and  butter.      Biscuits  with 
butter. 
Tea  and  cream,  butter-rolls,  scraped  ham  and  a  soft  egg. 
Rice    broth   or    soup;    puree    of    spinach,    carrots,    or    peas; 
chopped   chicken,  boiled   calves'  brain  or  fish;   and  some 
sweet  fruit-sauce. 
Cocoa  with  cream,  and  butter-cakes. 
A  cereal  soup  or  broth,  containing  much  butter. 
7:15    "        Tea  with  plenty  of  cream,  scraped  ham,  and  butter-rolls. 

The  art  of  the  chef  will  be  taxed  to  arrange  suitable 
variations  in  the  diet.  For  instance, — lean  fish,  cooked  in 
butter,  makes  a  pleasing  substitute  in  the  well-known  repug- 
nance of  cancer-patients  toward  meats. 

In  carcinoma  of  the  cardia,  the  semi-solid  and  liquid  forms 
of  diet  should  be  given,  as  in  cancer  of  the  pylorus.  A  gain 
in  weight  is  no  more  to  be  expected  here  than  in  cancer  of  the 
pylorus,  because  the  patient  cannot  be  properly  nourished. 

Mechanical  Treatment. — Mechanical  treatment  is  to  be 
resorted  to  only  in  carcinom^a  of  the  pylorus.  The  stomach 
should  be  washed  out  every  morning,  after  which  75  to  100 
c.c.  of  warm  olive  or  almond  oil  should  be  introduced.  If  the 
stenosis  is  not  of  a  high  degree,  the  stagnation  of  the  contents 
of  the  stomach  will  soon  be  lessened  by  this  treatment,  pro- 
vided the  diet  is  adapted  to  the  degree  of  stenosis  present. 

The  most  important  indications  to  be  fulfilled  by  lavage 
and  the  oil-treatment  are  the  relief  of  pyloric  spasm,  boring 
pains  ill  the  stomach,  and  offensive  eructations, — by  which 
changes  the  appetite  of  the  patient  is  often  greatly  improved. 

Cardiac  and  extra-ostial  carcinomata  require  no  mechanical 
treatment,  especially  since  former  attempts, — to  dilate  malig- 
nant stenosis  of  the  cardia  and  to  introduce  a  permanent 
cannula, — are  no  longer  resorted  to. 

Medicinal   Treatment. — The   medicinal  treatment   has   in 
view,  first  of  all,  the  iricreasing  of  the  appetite,  the  improving 
of  the  digestion,  and  the  relief  of  the  suffering. 
10 


146  DISEASES  OF  THE  DIGESTIVE  CANAL 

These  indications  arc  accomplished,  as  a  rule,  by  the 
use  of  the- following  prescriptions: 

1.  TJ     Extract!  condurango  fluidi,  oii  00.0 

Sig. — One-half  to  one  teaspoonful  before  meals,  t.i.d. 

2.  !>     Extracti  cinchonce  fluidi,  oi  30.0 
Sig. — Twenty  drops  t.i.d. 

3.  I^     Tincturse  belladonna?  foiiorum,  oiiss    10.0 

Tincturae  gentianse,  5>^i  -lO.O 

M.  Sig. — One-half  teaspoonful  before  meals, 
t.i.d.,  in  carcinoma  of  the  pylorus. 

4.  I^     Acidi  hydrochlorici  diluti,  oiiss  10.0 

Tincturse  rhei,  ov  20.0 

M.  Sig. — Thirty  drops  in  a  wineglassful  of 
water  after  eating. 

The  artificially  prepared  foods, — such  as  somatose, 
eucasin,  puro,  Valentine's  meat-juice,  sanatogen,  etc., — are 
satisfactor}^  substitutes  for  meat.  Three  or  four  teaspoonfuls 
of  an}^  of  the  above  should  be  given  daily,  preferably  cooked 
in  milk  or  soup.     The  various  infant-foods  are  also  valuable. 

In  general  practice,  I  frecjuently  prescribe  pancreon, 
just  as  in  benign  atrophy  of  the  mucous  membrane. 

b.  Surgical  Treatment. — Three  surgical  procedures  should 
be  considered, — namely,  gastrotomy,  resection  of  the  pylorus, 
and  gastro-enterostomy. 

Gastrotomy  should  be  performed  in  carcinoma  of  the 
cardia  or  of  the  lower  portion  of  the  oesophagus,  when  the 
cancer  has  caused  almost  complete  atresia  and  the  patient 
vomits  eveiy thing  that  is  eaten,  including  liquids. 

In  extra-ostial  carcinomata,  operative  procedures  are 
generally  contraindicated,  for  the  reason  that  the  life  of  the 
patient  is  maintained  equally  as  long  by  internal  treatment; 
furthermore,  cancers  which  do  not  involve  either  orifice  of 
the  stomach  are  not  often  recognized  at  a  time  when  total 
extirpation  is  possible. 

The  proper  domain  of  the  surgeon  is  carcinoma  of  the 
pylorus, — which,  unfortunately,  is  too  often  not  operated  on 
early  enough,  at  a  time  when  radical  removal  is  possible. 


DISEASES  OF  THE  STOMACH  147 

The  physician  is  in  duty  bound  to  consider  operation  in 
every  case  of  cancer  of  the  stomach  in  which  there  is  stagna- 
tion of  the  stomach-contents  with  lactic-acid  fermentation. 
By  so  doing,  he  will  avoid  merited  censure  for  culpable  delay 
and  neghgence. 

It  is  unfortunate  that  patients  so  frequently  refuse 
operative  measures  until  internal  treatment, — such  as  lavage, 
etc., — have  proved  ineffective,  when  it  is  often  too  late. 

It  should  always  be  left  to  the  decision  of  the  surgeon, 
after  he  has  opened  the  abdominal  cavity,  whether  he  will 
perform  a  radical  operation, — such  as  resection, — or  a  gastro- 
enterostomy, as  a  palliative  measure.  If  the  tumor  has  not 
proliferated,  and  no  metastases  into  the  liver  and  lymph- 
glands  have  occurred,  resection  should  be  attempted;  other- 
wise, gastro-enterostomy  is  the  proper  procedure. 

It  is  now  well  known  that  such  patients,  if  they  survive 
the  operation,  often  increase  in  weight  from  30  to  40  pounds 
within  a  few  months,  and  even  live  several  years  without 
gastric  discomfort.  Cases  have  been  reported  in  which  no 
return  of  the  symptoms  occurred  five  or  six  years  following 
operation. 

[Both  Kocher's  and  Robson's  mortality  in  gastrectomy, 
up  to  the  present  time,  is  15  per  cent.;  while  the  Mayos 
have  a  mortahty  of  only  10  per  cent.  In  their  last  twenty- 
five  cases  of  gastrectomy,  there  was  only  one  death. 

Robson  has  recently  collected  data  on  27  cases  of  gastrec- 
tomies, of  which  10  were  living  at  periods  of  8,  7,  6,  and  down 
to  2  years  after  operation.* 

In  view  of  the  fact  that  such  results  are  being  obtained 
by  the  surgical  treatment  of  gastric  carcinoma,  it  would  appear 
that  the  internist  who  fails  to  give  his  patient  the  advantage 
of  early  operation  is  assuming  an  unwarranted  responsibility. 

Early  diagnosis  and  good  surgery  are  the  requisites  in 
the  treatment  of  cancer  of  the  stomach.] 

*  [Keen 's  ' '  Surgery, "  1 907 .] 


148  DISEASES  OF  THE  DIGESTIVE  CANAL 

CLINICAL    CASES 

Extra-ostial  Carcinoma 

Case  1. — Von  M.,  an  editor,  50  years  old,  had  for  five  or  six  years 
suffered  from  dyspepsia  which  was  diagnosed  as  "atrophic  gastritis."  The 
mineral  water  "cure"  at  Kissingen  had  proved  highly  beneficial,  and  the 
patient  had  remained  in  good  health  until  eight  months  ago,  since  which 
time  he  had  experienced  loss  of  appetite,  pressure  in  the  stomach,  no  pain, 
occasional  vomiting,  and  emaciation.  Tumor  was  not  palpable.  There  was 
extreme  emaciation.  The  fasting  stomach  contained  blood  and  pus,  but  no 
food.  The  patient  was  put  to  bed,  and  he  improved  on  a  puree  diet  rich  in 
butter,  and  the  use  of  hydrochloric  acid.  He  gained  in  weight  from  1.52  to 
1G7  pounds,  was  able  to  resume  his  work  and  even  to  enjoy  the  sport  of 
hunting.    One  year  later,  however,  the  patient  died  from  cachexia. 

Case  2. — Bertha  H.,  a  housekeeper,  49  years  old,  had  been  sick  with 
"catarrh  of  the  stomach,"  jaundice,  loss  of  appetite,  diarrhoea,  and  gradual 
aggravation  of  the  symptoms  for  one  year.  At  the  time  of  examination, 
the  patient  had  severe  gnawing  and  cramp-like  pains  in  the  epigastrium 
after  eating.  She  was  markedly  emaciated  and  cachectic.  No  tumor  was 
palpable.  The  fasting  stomach  contained  mucus  and  pus-corpuscles.  The 
test-breakfast  was  achylous,  the  total  acidity  being  5. 

The  treatment  consisted  of  a  puree  form  of  diet,  rich  in  butter;  and 
the  use  of  hydrochloric  acid.  During  the  following  month,  the  patient 
improved  and  increased  20  pounds  in  weight;  but  died  seventeen  months 
later  from  cachexia,  at  which  time  a  tumor  was  palpable. 

Carcinoma  of  the  Pylorus 

Case  1. — Ernst  S.,  a  merchant,  55  years  old,  had  been  healthy  until 
five  weeks  before  the  first  symptom,  since  which  time  he  had  had  a  poor 
appetite  and  had  suffered  from  frequent  vomiting  after  eating  solid  foods. 
The  stagnating  stomach-contents, — for  instance,  grapes,  which  had  been 
eaten  a  few  days  before,— were  also  vomited  at  times.  The  bowels  were 
regular.  He  had  suffered  from  pressure  and  a  gna^\^ng  sensation  in  the 
epigastrium  after  eating  solids.  Previous  to  his  illness,  the  patient  had 
always  had  good  digestion.  The  physical  examination  showed  that  the 
patient  was  a  strongly-built  man.  He  was  sallow  and  emaciated.  No  tumor 
was  palpable.  The  greater  curvature  extended  to  the  level  of  the  umbilicus. 
Stagnating  foods  were  obtained  from  the  stomach  which  had  an  odor  of 
hydrogen  sulphide  gas.  Free  hydrochloric  acid  and  also  sarcina?  were 
present.    The  total  acidity  was  52.    Lactic  acid  was  absent. 

The  treatment  consisted  of  a  suitable  diet,  the  use  of  condurango, 
and  lavage  of  the  stomach.  After  ten  days,  there  was  no  stasis  of  food,  and 
pain  had  disappeared.     Free  hydrochloric  acid  was  present.     No  tumor 


DISEASES  OF  THE  STOMACH  149 

was  palpable.  Six  weeks  later,  the  patient  had  increased  seven  pounds  in 
weight.  He  remained  in  good  condition  on  a  puree  diet  without  lavage 
treatment,  and  resumed  his  occupation.  Two  months  later,  the  test-supper 
was  given  and  lavage  in  the  morning  showed  that  there  was  stagnation 
of  the  stomach-contents,  with  lactic-acid  fermentation.  Oppler-Boas  bacilli 
and  a  few  sarcina?  were  present.  During  the  next  four  weeks,  the  patient 
increased  three  pounds  in  weight.  During  the  summer  after  indulging 
in  errors  in  diet,  he  suffered  from  diarrhoea  and  lost  ten  pounds  in  one  week, 
after  which  he  improved  again  and  gained  six  pounds  in  weight.  While 
travelling  and  taking  his  meals  in  restaurants,  he  ate  a  meal  of  veal  cutlets, 
returned  to  his  home  ill,  and  died  within  two  weeks, — just  eleven  months 
after  commencing  treatment. 

There  was  atresia  of  the  pylorus.  A  tumor,  after  considerable  emacia- 
tion had  occurred,  was  palpable. 

Carcinomatous  Ulcer 

Case  1. — Ernst  H.,  a  laborer,  58  years  old,  had  had  hsematemesis, 
preceded  and  followed  by  cramp-like  pains  in  the  epigastrium,  with  vomit- 
ing. He  had  remained  well  until  two  weeks  previous.  The  present  illness 
began  with  pain  in  the  stomach,  vomiting,  and  icterus.  The  patient  was 
emaciated  aud  cachectic.  A  tumor,  the  size  of  the  fist,  was  palpated  in  the 
epigastrium.     There  Avas  no  stagnation  of  the  stomach-contents. 

Case  2. — Carl  T.,  a  teamster,  52  years  old,  had  suffered  three  years 
previous  from  epigastralgia,  ha^matemesis,  gastrosuccorrhcea,  and  hyper- 
chlorhydria.  (Total  acidity  was  90.)  Symptoms  had  disappeared  through 
dieting  and  the  oil-treatment.  Four  weeks  ago,  the  patient  suffered  a  relapse, 
with  stagnation  of  the  stomach-contents  and  vomiting.  At  first,  lavage 
and  the  oil-treatment  were  beneficial.  In  the  course  of  the  following  six  or 
eight  weeks,  the  hyperacidity  of  the  gastric  juice  passed  into  subacicUty. 
Sarcinte,  which  had  been  present,  were  then  absent.  Patient  at  first  refused 
to  undergo  an  operation,  and  died  six  days  after  surgical  treatment  was 
finalh^  resorted  to. 

The  autopsy  showed  the  presence  of  a  carcinomatous  ulcer  of  the 
pylorus. 

Case  3. — Ernst  P.,  an  inspector,  44  years  old,  had  had  periodical 
attacks  of  epigastralgia  for  twenty  years,  usually  in  the  spring  and  autumn. 
Three  years  previous,  patient  had  metena.  For  six  months  past,  he  had 
suffered  constantly  from  gnawing  and  cramp-like  pains  in  the  epigastrium, 
which  were  especially  severe  after  eating  sohds.  No  tumor  was  palpable. 
Blood,  pus,  and  mucus  were  obtained  from  the  fasting  stomach.  The 
test-breakfast  was  entirely  achylous.    The  patient  was  cachectic. 

Case  4. — Emma  S.,  a  laboring  woman,  37  years  old,  had  had  symp- 
toms of  gastric  ulcer, — gnawing,  cramp-hke  pains,  vomiting  of  blood,  and 
heartburn, — for  fifteen  years.    She  had  been  temporarily  relieved  by  Leube's 


150  DISEASES  OF  THE  DIGESTIVE  CANAL 

ulccr-curc.  A  cicatrization  of  the  ulcer  had  occurred,  which  caused  food- 
stasis.  Castl'o-onterostoniy  was  performed,  which  was  followed  by  a  dis- 
appearance of  all  symptoms  for  two  or  three  years,  patient  gaining  consider- 
ably in  weight.  But  after  this  period,  a  tumor,  as  large  as  two  fists,  gradually 
developed  behind  the  laparotomy  cicatrix.    She  died  later  from  cachexia. 

Epigastric  Hernia 

The  epigastric  hernia?  are  found  in  the  hnea  alba,  vary- 
ing in  size  from  a  pea  to  a  hazel-nut.  These  herniic  usually 
consist  of  only  the  fatty  tissues  of  either  the  greater  or  the 
lesser  omentum.  It  is  very  rare  for  a  coil  of  the  intestine  to 
be  a  part  of  such  a  hernia. 

Epigastric  hernise  result  from  direct  blows  against  the 
abdomen,  lifting  heavy  weights,  or  subjecting  the  abdominal 
muscles  to  sudden  tension,  or  severe  coughing  spells.  The  fis- 
sure occurring  in  the  fascia  is  always  transverse,  never  vertical. 

Symptoms. — The  most  prominent  symptom  of  epigastric 
hernia  is  the  occurrence  of  severe  pain  when  lifting,  coughing, 
sneezing,  straining,  etc.  This  pain  is  caused  by  strangulation 
of  the  omentum,  and  generally  disappears  when  the  patient 
assumes  a  recumbent  position.  Frequently  these  hernise 
produce  no  symptoms. 

Objectively,  the  physician  can  diagnose  the  hernia  very 
easily  if  he  directs  the  patient  to  cough  during  the  examination. 

Diagnosis. — The  diagnosis  of  epigastric  hernise  is  usually 
very  easy,  if  the  phj^sician  has  in  mind  the  possibility  of  the 
occurrence  of  such  hernise. 

The  affection  may  be  confused  with  other  kinds  of  hernia?, 
attacks  of  colic,  appendicitis,  and  particularly  ulcer  of  the 
stomach,  especially  when  in  epigastric  hernia  the  lesser 
omentum  becomes  incarcerated  in  a  fissure  of  the  fascia  in 
the  neighborhood  of  the  pylorus.  In  this  condition,  the  pains, 
which  are  similar  to  those  of  ulcer,  occur  regularly  two  or 
three  hours  after  eating,  at  a  time  when  the  omentum  is 
subject  to  the  greatest  traction  and  disturbance  from  the 
active  movement  of  the  pylorus.  Careful  inspection,  however, 
will  usually  prevent  confusion  in  the  differential  diagnosis 
of  the  two  affections. 


DISEASES  OF  THE  STOMACH  151 

Treatment. — The  physician  should  first  reduce  the  hernia 
and  then  apply  a  hernia  bandage,  or  adhesive  plaster,  as  in 
fracture  of  the  ribs,  using  care  to  avoid  strong  tension  of  the 
abdominal  muscles.  It  may  be  necessary  to  give  morphine 
to  prevent  attacks  of  coughing.  Naturally,  irreducible  hernise 
are  frequently  encountered,  from  which  rehef  can  be  obtained 
only  by  surgical  treatment. 

CLINICAL    CASES 

Case  1. — Otto  G.,  a  merchant,  30  years  old,  had  suffered  for  six  or 
seven  weeks  from  pains  in  the  region  of  the  stomach,  especially  after  lifting, 
bending,  or  reaching  high.  Nothing  that  the  patient  ate  disagreed  with 
him.  There  was  a  sm.all  gastric  hernia,  which  was  treated  by  bandaging 
and  the  application  of  iodine,  and  a  cure  resulted. 

Case  2. — Mr.  0.,  a  shipping  clerk,  40  years  old,  had  suffered  for  two 
years  from  violent  pains  in  the  region  of  the  stomach,  about  two  hours  after 
eating.  The  pains  always  disappeared  if  he  assumed  a  recumbent  position. 
The  patient  had  hyperchlorhydria,  the  total  acidity  of  the  test-breakfast 
being  70.      Two  epigastric  herniae,  about  the  size  of  peas,  were  found. 

The  subsequent  history  of  the  case  is  unknown,  as  the  patient  did  not 
retm-n  to  the  clinic, — having  been  advised  to  undergo  a  surgical  operation. 

Qastrectasis 

(Stenosis  of  the  Pylorus,  Mechanical  Insufficiency,  Vitium 
Pylori  or  Duodeni) 

Definition. — At  the  present  time,  we  understand  the 
expression,  "dilatation  of  the  stomach,"  to  mean  that  form 
of  gastric  disturbance  in  which  the  stomach  is  unable  to  empty 
itself  of  its  contents,  with  a  resulting  persistent  stagnation  of 
food.  The  location  of  the  greater  curvature  is,  in  itself,  irrel- 
evant in  the  diagnosis  of  dilatation  of  the  stomach.  The 
question  is  not  as  to  the  size  of  the  stomach,  but  only  as  to 
its  motor  function. 

The  term  "gastrectasis"  originated  at  a  time  when 
physicians  had  not  learned  to  recognize  the  initial  stage  of  the 
affection,  but  only  its  final  stage, — dilatation  of  the  organ, — and 
this  was  considered  the  most  significant  symptom  of  the  disease. 
When  we  use  the  expression,  ''dilatation  of  the  stomach," 
therefore,  we  must  from  the  outset  be  clear  that  we  mean  only 
the  symptom  of  an  actual  disease,  rather  than  a  disease  per  se. 


152  DISEASES  OF  THE  DIGESTIVE  CANAL 

To  make  the  condition  quite  clear,  a  comparison  of  the 
stomach  \yith  the  heart  is  very  appHcable;  for  just  as  acute 
dilatation  of  the  ventricles  of  the  heart  ma}'  arise  from  valvular 
insufficiency,  so  acute  dilatation  of  the  stomach  may  occur 
from  overloading  this  organ,  as  a  result  of  errors  in  diet,  or 
from  paralysis  of  its  nerve-muscular  apparatus. 

On  the  other  hand,  chronic  dilatation  of  the  stomach  is, 
without  exception,  the  result  of  an  obstruction  at  the  pylorus 
or  duodenum,  just  as  hypertrophy  and  dilatation  of  the 
ventricle  result  from  valvular  affections.  Hence  the  primar}'' 
factor  is  always  an  obstruction  which  causes  stagnation  of  the 
food,  this  in  turn  producing  dilatation  of  the  stomach. 

Every  dilatation  of  the  stomach  is,  therefore,  a  vitium 
pylori  or  duodeni  (obstruction),  in  the  stage  of  disturbed 
compensation. 

.  As  has  already  been  mentioned,  it  is  necessary  to  differ- 
entiate between  acute  and  chronic  forms  of  motor  insufficiency 
of  the  stomach.  Acute  dilatation  is  extremely  rare  and,  in 
general,  corresponds  to  acute  gastritis  after  indigestion,  or 
to  ileus  which  is  located  high  up  in  the  intestine.  Its 
details,  therefore,  will  be  described  in  the  chapters  on  these 
affections. 

Etiology. — The  cause  of  actual  dilatation  of  the  stomach 
is  a  mechanical  obstruction  at  the  stomach-outlet,  the  so- 
called  vitium  pylori.  The  assumption  of  the  existence  of 
primary  muscular  weakness  of  the  stomach,  as  a  cause  of 
chronic  dilatation,  has  now  been  quite  generally  abandoned. 

Apart  from  malignant  stenosis  of  the  pylorus,  with  second- 
ary gastrectasis,  which  has  been  considered  in  detail  in  the 
foregoing  chapter  on  Carcinoma  of  the  Stomach,  there  are 
two  general  groups  of  a  benign  nature  that  cause  a  narrowing 
of  the  stomach-outlet,  the  accurate  understanding  and  knowl- 
edge of  which  are  indispensable  to  a  clear  recognition  and 
treatment  of  this  affection. 

The  first  group  includes  those  causal  factors  which  pro- 
duce an  organic  and  irreparable  change  of  the  entire  'pars 
pylorica,  or  of  the  pylorus  itself. 


DISEASES  OF  THE  STOMACH  153 

These  alterations  may  be  caused  by  pathological  lesions 
from  within,  such  as  cicatricial  contraction  of  the  pylorus 
following  ulcer;  or  from  without,  such  as  perigastritis,  chole- 
lithiasis, adhesions  with  the  pancreas,  liver,  and  the  anterior 
abdominal  wall,  and  finally  compression-stenosis  and  the 
kinking  of  the  duodenum  in  enteroptosis. 

The  second  group  includes  those  causative  factors  that 
have  produced  a  reparable,  functional  stenosis  of  the  pylorus. 
Of  these,  spasm  of  the  pylorus  is  most  important,  which  occurs 
in  fissures,  erosions,  small  ulcers,  and  scars  of  the  pylorus. 
It  is  never  observed  in  neuroses. 

A  transitory  narrowing  of  the  stomach-outlet,  which 
gives  rise  to  a  temporary  dilatation  of  the  stomach,  is  some- 
times the  result  of  inflammatory  swelling  of  the  tissues  of 
the  pylorus  surrounding  an  ulcer. 

Likewise,  acute  traumata  of  the  epigastrium  may,  by 
resulting  ulceration  of  the  pylorus,  lead  to  stenosis  and  ulti- 
mate gastrectasia.  Such  a  trauma  causes  either  a  necrosis  of 
the  mucosa  or  the  formation  of  a  hsematoma  between  the 
mucosa  and  the  muscularis. 

From  the  digestion  of  the  necrotic  areas,  an  ulcer  results 
which  may  lead  to  a  mechanical  obstruction  of  the  stomach- 
outlet,  either  from  spasm  of  the  pylorus  or  from  the  formation 
of  scar-tissue  in  the  pylorus. 

Obstruction  of  the  stomach-outlet  with  dilatation  of  the 
organ  is  also  caused  by  peritoneal  adhesions  around  the 
pylorus,  following  traumatism  to  the  epigastrium.  Ectasia 
of  traumatic  origin  is,  however,  of  rather  rare  occurrence. 

The  diseases  which  ultimately  lead  to  gastrectasis  are, 
in  the  order  of  their  frequency,  the  following: 

Ulcer  of  the  pylorus  and  of  the  antrum  of  the  pylorus, 
.erosions  and  fissures,  perigastric  adhesions,  duodenal  ulcer, 
gall-stones  with  pericholecystitis,  enteroptosis,  gastric  hernia, 
traumata,  and  foreign  bodies  which  have  been  swallowed 
and  which  obstruct  the  stomach-outlet.  It  is  self-evident 
that  a  swelling  of  any  kind  within  the  pylorus,  malignant  or 
benign,  as  well  as  the  enlargement  of  adjacent  organs  which 


154  DISEASES  OF  THE  DIGESTIVE  CANAL 

may  compress  the  stomach-outlet, — such  as  the  hver,  gall- 
bladder, pancreas,  and  duodenum, — may  be  capable  of  caus- 
ing dilatation  of  the  stomach. 

"We  have  therefore,  etiologically,  two  forms  of  gastrec- 
tasis,  according  to  whether  the  obstructions  are  irreparable 
or  organic,  and  reparable  or  functional. 

In  both  forms,  apart  from  malignant  cases,  hyperchlor- 
h3'dria  and  h3"persecretion  are  almost  alwa3''s  present,  provided 
the  disease  has  already  existed  long  enough  for  the  gastric 
glands  to  have  been  subjected  to  sufficient  irritation  from  the 
stagnation  of  the  stomach-contents.  Hyperchlorhydria  associ- 
ated with  stenosis  of  the  pylorus  is,  therefore,  never  the  cause  of 
gastrectasis,  but  the  result  of  it,  with  the  exception  of  the  above- 
mentioned  acid  gastritis  associated  with  erosions  of  the  pylorus. 

The  spastic  forms  of  gastrectasis,  which  often  run  an 
intermittent  course,  are  worthy  of  special  mention;  for  just 
as  often  as  there  is  a  recurrence  of  the  ulcers  or  erosions  of 
the  pylorus,  just  so  often  will  occur  inflammatory  swelhng 
and  spastic  stenosis  of  the  p^dorus,  which  cause  motor  insuf- 
ficienc}^  of  the  stomach.  Thus,  patients  who  once  or  twice 
during  every  year,  especially  in  the  spring  or  autumn,  suffer 
a  few  weeks  from  dilatation  of  the  stomach  will  be  reheved 
of  the  dilatation  as  soon  as  the  lesion  of  the  p^dorus  is  cured, 
by  adherence  to  suitable  treatment  and  diet;  and  will  remain 
free  from  the  trouble  for  several  months,  until  there  is  a  recur- 
rence of  the  erosion  or  ulcer  from  errors  in  diet  or  from  some 
mechanical  cause. 

It  should  be  mentioned  here,  that  stenoses  resulting 
from  organic  lesions  are  frequently  aggravated  by  spasm  of 
the  pylorus;  for  instance,  pyloric  spasm  results  from  inflam- 
mation and  irritation  of  the  old  cicatrix  of  an  ulcer. 

Symptoms. — The  most  significant  symptoms  obtained 
in  the  anamnesis  of  patients  suffering  from  gastrectasis  is 
copious  vomiting,  which  in  severe  cases  occurs  daily,  and  in 
light  cases  only  now  and  then. 

The  vomiting  of  food  which  has  been  eaten  on  one  of  the 
preceding  da^^s,  is  characteristic  of  dilatation  of  the  stomach. 


DISEASES  OF  THE  STOMACH  155 

It  sometimes  happens  that  fruits,  cereals,  and  vegetables, 
especially  grapes,  raisins,  rice,  and  other  heavy  ingesta  which 
easily  sink  to  the  bottom,  are  not  vomited  for  several  weeks 
after  they  are  eaten.  In  mild  cases,  sometimes  only  a  sour 
fluid  (gastric  juice)  is  vomited  several  hours  after  meals, — 
therefore  late  in  the  afternoon  or  at  night.  These  are  the  cases 
caused  by  a  slight  cicatricial  stenosis,  in  which  there  is  only  a 
relative  stenosis  of  the  pylorus.  In  order  to  obtain  relief, 
these  patients  frequently  produce  artificial  vomiting  by  tickling 
the  palate  with  the  finger. 

After  vomiting,  the  patients  with  gastrectasia  usually 
feel  very  well  and  eat  with  a  good  appetite  until  the  stomach 
is  again  over-filled,  which  induces  vomiting  anew. 

The  subjective  symptoms  that  most  frequently  annoy 
the  patient  with  ectasia  are  gnawing,  cramp-hke,  burning, 
boring  pains  in  the  epigastrium,  similar  to  those  in  ulcer, 
which  are  relieved  only  when  the  patient  either  naturally 
or  artificially  empties  the  stomach  of  its  contents.  Other 
subjective  disturbances  are  heartburn,  the  feeling  of  fulness, 
and  constant  distention  of  the  abdomen,  except  immediately 
after  vomiting  or  lavage. 

The  appetite  in  benign  ectasia  is  generally  good,  although 
the  nutrition  of  the  patient  usually  suffers  considerably  because 
of  his  being  afraid  to  eat.  (Constipation  and  general  emacia- 
tion set  in  for  the  same  reason.)  In  addition  to  this,  the 
assimilation  of  food  is  much  impaired  because  it  is  not  pro- 
pelled into  the  duodenum  normally.  This  is  the  chief  factor 
in  producing  impairment  of  nutrition.  Patients  suffering 
from  ectasia  are  frequently  seen  emaciated  almost  to  mere 
skeletons,  so  that  the  physician  at  first  thinks,  naturally,  that 
he  has  cancer  to  deal  with. 

The  decrease  in  weight  of  the  patient  in  ectasia  must  be 
ascribed  in  part  to  the  deprivation  of  the  organism  of  water; 
and  the  thirst,  corresponding  to  the  diminished  absorption  of 
water,  is  usually  very  great. 

In  extreme  stages  of  gastrectasis,  where  a  high  degree  of 
drying  of  the  tissues  has  occurred,  there  frequently  develops 


156  DISEASES  OF  THE  DIGESTIVE  CANAL 

the  symptom-complex  of  tetany,  a  neurosis  characterized  by 
tonic  spas-ms  of  the  extremities,  usually  resulting  in  death. 
A  portion  of  the  fatal  cases  of  gastrectasis  is  to  be  attributed 
to  this  affection. 

In  gastrectasis  there  is  almost  always  a  diminution  in  the 
amount  of  urine  secreted.  The  higher  the  degree  of  p3doric 
obstruction,  the  smaller  the  amount  of  urine  secreted, — a 
fact  which  is  sufficiently  explained  by  the  physiological  fact 
that  water  is  not  absorbed  in  appreciable  amounts  from  the 
stomach.  The  amount  of  urine  secreted  is,  therefore,  a  direct 
measure  of  the  degree  of  the  obstruction  at  the  pylorus. 

In  carcinoma  of  the  pylorus,  in  which  a  complete  clinical 
atresia  often  occurs,  the  amount  of  urine  secreted  in  twenty- 
four  hours  does  not  exceed  400  to  500  c.c. 

Objective  Symptoms. — The  external  demonstrable  signs 
of  ectasia  are  the  low  position  of  the  greater  curvature  of  the 
stomach,  and  the  "  stomach-stiff enings, "  first  defined  by 
Boas,  which  are  increased  peristaltic  waves  of  the  stomach 
running  from  the  cardia  to  the  pylorus,  externally  perceived  on 
the  abdominal  wall.  The  "stomach-stiffenings"  are  an  abso- 
lute symptom  of  stenosis  of  the  pylorus,  and  are  very  easily 
recognized,  because  such  a  patient  usually  has  a  very  thin  and 
relaxed  abdominal  wall,  and  the  wall  of  the  stomach  lies  in  al- 
most direct  apposition  to  the  skin  covering  the  abdominal  wall. 

The  low  position  of  the  greater  curvature,  which  the 
examiner  will  usually  recognize  by  means  of  Obrastzow's 
method  (see  General  Section,  page  11),  often  leads  the 
inexperienced  into  error,  because  of  the  fact  that  the  low 
position  of  the  greater  curvature  also  occurs  in  ptosis  and  in 
the  vertical  position  of  the  stomach,  and  in  megalogastria, — 
the  so-called  phj^siologically  enlarged  stomach, — as  well  as 
in  the  case  of  large  eaters  and  heavy  drinkers. 

The  significance  of  the  splashing  sounds  in  the  epigastrium 
below  the  umbilicus  is  often  misinterpreted  as  indicating 
dilatation,  because  they  occur  quite  as  frequently  in  gastrop- 
tosis  and  associated  conditions,  the  details  of  which  are 
considered  in  the  chapter  on  Atony  of  the  Stomach. 


DISEASES  OF  THE  STOMACH 


157 


Since  the  splashing  sounds  may  be  produced  by  heavy 
palpation  when  only  small  quantities  of  secretion  are  present 
in  the  fasting  stomach,  it  is  evident  how  slight  a  value  this 
symptom  possesses  in  estimating  the  degree  of  stagnation  of 
the  stomach-contents. 

P'iG.  29. 


Gastrectasia  secondary  to  iiloer  of  the  pylorus.    The  stomach-stiffenings  were  easily  recognized 
in  this  case.    [Courtesy  of  Dr.  W.  W.  Hitchcock,  Los  Angeles.] 

The  use  of  the  stomach-tube  and  an  examination  of  the 
fasting  stomach  furnish  the  only  absolute  proof  of  the  presence 
of  dilatation  of  the  stomach.  If  remnants  of  food  are  found 
in  repeated  examinations  by  this  method,  gastrectasis  may 
be  diagnosed. 

If  no  food-remnants  are  obtained  from  the  fasting  stom- 
ach, dilatation  may  be  excluded  from  the  diagnosis, — whether 
the  greater  curvature  stands  above  or  below  the  umbilicus. 


158  DISEASES  OF  THE  DIGESTIVE  CANAL 

If  considerable  amounts  of  gastric  juice, — for  instance, 
40  to  50  c.c, — can  be  obtained  from  the  fasting  stomach, 
the  examiner  may  assume  the  i)resence  of  hypersecretion, — 
which  will  be  considered  in  detail  in  a  special  chapter. 

In  benign  stenosis  of  the  pylorus,  hydrochloric  acid  is 
always  present;  and  in  almost  all  cases,  there  are  both  hyper- 
chlorhydria  and  hypersecretion, — the  result  of  increased  irrita- 
tion of  the  gastric  glands  from  the  stagnation  of  food.  Occasion- 
ally the  physician  will  find  a  normal  or  a  subacid  gastric  juice, 
when  stagnation  has  existed  so  long  that  the  functional  ability 
of  the  gastric  glands  has  become  exhausted  from  over-activity. 

In  gastrectasis,  the  total  acidity  of  the  contents  removed 
from  the  fasting  stomach  usually  exceeds  100,  since,  in  addi- 
tion to  the  normal  acids  of  the  stomach,  there  are  present  the 
acids  resulting  from  fermentation  and  those  introduced  with 
the  food,  especially  sarcolactic  acid.  Total  acidities  amount- 
ing to  from  150  to  160  are  not  at  all  rare. 

In  malignant  stenosis  of  the  pylorus,  free  hydrochloric 
acid  is  not  found  in  the  stagnating  contents  of  the  stomach; 
fermentation-acids  only  are  present,  especially  lactic  acid. 
In  the  early  stages  of  a  primary  carcinoma  of  the  p3dorus,  free 
hydrochloric  acid  is  also  encountered. 

If  the  examiner  finds  a  stenosis  of  the  pylorus  in  which 
there  is  a  diminished  hydrochloric  acid  secretion  in  the  stag- 
nating food,  and  the  anamnesis  points  to  the  presence  of  an 
ulcer,  this  combination  of  symptoms  should  always  awaken 
his  suspicion  of  a  malignant  degeneration  of  the  ulcer. 

Such  a  patient  should,  as  already  mentioned,  be  referred 
to  the  surgeon  at  the  earliest  possible  moment. 

In  benign  stenosis,  sarcinse  and  yeast-cells  are  always  micro- 
scopically present,  while  in  malignant  stenosis  there  are  always 
enormous  numbers  of  lactic  acid  bacilli,  besides  yeast-cells. 

For  further  details  see  the  chapter  on  Microscopical 
Examination  of  the  Contents  of  the  Stomach. 

Diagnosis. — The  diagnosis  of  dilatation  of  the  stomach 
is  very  easy.  It  is  much  more  difficult  to  determine  which 
form  of  dilatation  is  present  in  an  individual  case. 


DISEASES  OF  THE  STOMACH  159 

If  stagnating  foods  are  obtained  from  the  fasting  stomach, 
it  is  certain  that  there  is  a  mechanical  obstruction  of  the 
pylorus;  and  if  the  greater  curvature  of  the  stomach  lies 
below  the  umbilicus,  this  obstruction  has  caused,  in  addition 
to  food-stasis,  an  enlargement  of  the  stomach. 

Unless  the  patient  states  definitely  in  the  anamnesis 
that  he  has  frequently  vomited  food  eaten  one  or  several 
days  before,  the  chnician  can  never  make  a  diagnosis  of 
gastrectasis  before  he  has  introduced  the  stomach-tube  into 
the  fasting  stomach  and  has  demonstrated  thereby  that 
foocl-stasis  exists. 

To  determine  the  character  of  the  obstruction  is  often 
very  difficult.  If  the  occurrence  of  dilatation  has  been  preceded 
by  periodical  epigastralgia  (see  chapter  on  Ulcer),  and  if, 
besides  this,  hsematemesis  has  been  observed,  it  is  extremely 
probable  that  a  cicatrized  ulcer  of  the  pylorus  is  the  cause  of 
the  gastrectasis. 

If  gall-stone  colic  with  icterus,  or  an  injury  to  the  epi- 
gastrium, can  be  clearly  established,  the  diagnostician  will 
naturally  think  of  the  presence  of  adhesions  from  perigastritis 
which  compress  the  pyloric  outlet. 

If  the  dilatation  has  existed  only  a  short  time,  in  an 
otherwise  previously  healthy  individual,  a  malignant  neo- 
plasm of,  or  near,  the  pylorus  should  be  suspected,  especially 
if  examination  shows  that  there  is  a  diminished  secretion  of 
hydrochloric  acid. 

Gastrectasis  due  to  spasm  of  the  pylorus  should  always 
be  thought  of,  if  colicky  pains  occur  regularly  at  certain  periods 
of  the  day,  especially  four  to  six  hours  after  meals,  at  five  or 
six  o'clock  in  the  afternoon  and  from  one  to  three  o'clock  at 
night. 

An  exact  diagnosis  of  the  etiology  of  dilatation  of  the 
stomach  will  usually  require  a  prolonged  clinical  observation 
of  the  case. 

Slight  or  latent  cases  of  relative  stenosis  of  the  pylorus 
are  recognized  by  the  administration  of  the  test-supper 
(see  page  35). 


160  DISEASES  OF  THE  DIGESTIVE  CANAL 

Differential  Diagnosis. — No  other  affection  can  be  easily 
confused  with  chronic  dilatation  of  the  stomach,  if  the  examiner 
has  obtained  stagnating  food  from  the  fasting  stomach. 

A  low  position  of  the  greater  curvature,  as  already  men- 
tioned, is  equall}'  frequent  in  enteroptosis,  in  vertical  position  of 
the  stomach  and  in  megalogastria.  If  the  physician  gives  the 
test-supper  and  finds  the  stomach  empty  in  the  morning  before 
breakfast,  gastrectasis  maj^  be  eliminated  from  the  diagnosis. 

Acute  gastrectasia,  which  is  a  form  of  ileus,  high  up  in 
the  bowel,  results  from  sudden  kinking  of  the  duodenum, 
incarceration  of  a  gall-stone,  and  paralysis  of  the  stomach 
following  laparotomies  and  abdominal  injuries. 

Acute  dilatation  ma}^  be  confused  with  the  dyspeptic 
symptoms  of  acute  gastritis.  The  low  position  of  the  greater 
curvature  best  protects  the  examiner  from  confusion  in  the 
differential  diagnosis  of  these  two  diseases. 

Prognosis. — The  prognosis  of  gastrectasis  depends  entirely 
upon  the  nature  of  the  original  disease. 

Gastrectasis  due  to  chronic  pylorospasm  offers  a  favor- 
able prognosis,  since  an  absolute  cure  is  possible,  the  stomach 
regaining  its  normal  motor  power. 

On  the  other  hand,  chronic  ectasia  caused  by  organic 
obstruction  at  the  pylorus  can  only  be  relatively  cured,  that 
is,  the  patient  must  occasionally  have  lavage  treatment  and 
use  a  stenosis-diet,  i.e.,  a  semi-sohd  diet  rich  in  fats. 

An  absolute  cure  can  be  expected  only  through  surgical 
intervention. 

The  prognosis  of  gastrectasis  must  be  very  guarded  in 
every  case  until  the  physician  is  convinced  of  the  nature  of 
the  obstruction.  The  greater  the  stagnation  of  food,  and  the 
smaller  the  amount  of  urine  secreted,  the  poorer  are  the 
chances  for  recovery.  The  prognosis  is  always  bad  if  symp- 
toms of  tetany  are  present. 

Treatment. — The  indications  for  treatment  in  the  dif- 
ferent forms  of  dilatation  are  as  follows: 

In  the  spastic  form  of  ectasia,  the  object  of  treatment 
should  be  to  reduce  the  inflammatory  swelling  of  the  pylorus, 


DISEASES  OF  THE  STOMACH  161 

or  to  heal  the  erosion  or  ulcer.  If  the  treatment  is  successful 
in  these,  the  pylorospasm  relaxes  and  the  gastrectasis  dis- 
appears of  itself. 

In  dilatation  of  the  stomach  due  to  organic  stenosis, 
on  the  other  hand,  the  task  of  the  physician  should  be  to 
reduce  the  obstruction  of  the  pylorus  to  the  stage  of  com- 
pensation, on  the  principle  that  every  dilatation  due  to  ob- 
struction represents  a  gastric  disturbance  in  the  stage  of 
disturbed   compensation. 

The  treatment  is  (1)  Dietetic,  (2)  Mechanical, 
(3)   Medicinal,  and  finally   (4)  Surgical. 

1.  Diet. — The  diet  should  be  suitable  to  the  anatomical 
conditions  present,  the  food  being  of  such  a  consistency  as 
will  pass  through  a  sieve,  the  perforations  of  which  are  about 
the  size  of  a  knitting-needle,  so  that  it  can  readily  pass  through 
the  narrowed  stomach-outlet.  It  must,  therefore,  be  liquid 
or  semi-liquid,  and  should  be  as  rich  in  fats  as  possible,  so  as 
to  contain  the  sufficient  number  of  calories  for  the  main- 
tenance of  the  body. 

Only  after  advanced  improvement  has  taken  place  will 
it  be  safe  for  the  physician  to  enlarge  the  dietary  to  foods  of 
pulpy  and  semi-solid  consistency. 

Meats  and  albuminous  foods  need  not  be  given  in  a  finely 
divided  form,  because  the  gastric  secretions  are  usually  pres- 
ent in  amounts  sufficient  for  normal  chymification. 

Only  in  the  malignant  forms  of  stenosis  of  the  pylorus 
need  the  food  be  given  in  a  liquid  or  semi-solid  form,  because 
in  these,  gastric  secretion  is  deficient. 

Of  foods  suitable  in  gastrectasis,  the  following  should 
be  especially  mentioned :  cream,  butter,  olive  oil,  milk,  butter- 
milk, meat  soups,  raw  eggs,  scraped  beefsteak,  beef  juice, 
meat-gelatins,  purees  of  potatoes,  carrots,  peas,  spinach,  and 
also  apple  and  orange  sauces;  and  for  drinks, — wine  or  fruit 
juices  diluted  with  mineral  water. 

Detailed  diet-lists  will  be  found  in  the  Dietetic  Outlines. 

2.  Mechanical  Treatment. — The  mechanical  treatment  of 
gastrectasia  consists  in  lavage  of  the  fasting  stomach,  which 

11 


16^2  DISEASES  OF  THE  DIGESTIVE  CANAL 

should  be  continued  daily,  until  it  no  longer  contains  stag- 
nating food.  In  the  beginning,  the  treatment  should  be 
given  daih',  then  twice  or  three  times  a  week,  and  finally 
only  once  a  week.  The  patient  may  soon  be  able  to  lavage 
the  stomach  himself.  Two  or  three  litres  of  pure  lukewarm 
water,  about  30°  R.  [100°  F.],  are  required  in  each  treatment. 

The  addition  of  medicinal  substances  to  the  lavage  water 
is  quite  superfluous. 

After  the  lavage,  from  50  to  100  c.c.  of  warm  olive  oil 
should  be  introduced  into  the  stomach,  or  if  preferable,  the 
patient  may  drink  the  oil,  in  order  that  the  narrowed,  rough- 
ened and  fissured  portion  of  the  mucosa  may  be  lubricated. 
Besides  its  usefulness  in  this  direction,  the  oil  also  effectively 
reduces  hyperchlorhydria,  and  at  the  same  time  increases  the 
number  of  calories  furnished  the  body. 

3.  Medicinal  Treatment. — Especially  deserving  mention 
are  silver  nitrate,  bismuth,  the  alkalies,  and  atropine. 

Remedies  such  as  bismuth,  silver  nitrate  and  atropine, 
which  are  directed  toward  the  removal  of  the  etiological 
factors,  should  be  given  before  meals;  while  such  drugs  as 
antacids,  whose  effect  is  purely  symptomatic,  should  be  given 
after  eating. 

As  a  rule,  for  the  treatment  of  spasm  of  the  pylorus, 
I  first  administer  the  oil- treatment;  and  later,  give  a  tea- 
spoonful  of  bismuth  in  the  morning  on  the  fasting  stomach, 
just  as  in  ulcer;  and  at  noon  and  in  the  evening,  one-half 
hour  before  meal-time,  a  ^  milligram  [gr.  y^-o]  tablet  of 
atropine  sulphate. 

Boas  has  recently  recommended  the  use  of  ten  drops  of 
a  one  per  mille  solution  of  eumydrin,  instead  of  atropine. 

One  or  two  hours  after  meals,  a  teaspoonful  of  magnesia 
usta,  magnesium  carbonate,  magnesium  ammonio-phosphate, 
bicarbonate  of  soda,  or  Vichy  salts,  should  be  given.  When 
indicated,  the  physician  may  prescribe  the  extract  of  bella- 
donna mixed  with  the  alkalies  in  powder  form. 

4.  Surgical  Treatment.  In  case  the  internal  treatment  is 
ineffectual,  if  in  spite  of  the  stenosis-diet,  stagnation  of  the 


DISEASES  OF  THE  STOMACH  163 

stomach-contents  still  persists,  and  the  daily  amount  of  urine 
secreted  amounts  to  only  500  or  600  c.c,  and  if  the  strength 
of  the  patient  is  gradually  failing,  the  physician  should  advise 
surgical  treatment. 

The  operator,  after  opening  the  abdominal  cavity,  should 
ciecide  whether  pyloroplasty,  resection  of  the  pylorus,  or  gastro- 
enterostomy is  indicated. 

As  a  rule,  the  latter  will  usually  be  the  most  suitable. 

The  clinician  must  be  all  the  more  ready  to  advise  opera- 
tion, if  the  stenosis  of  the  pylorus  is  of  a  mahgnant  nature. 

If  the  operation  is  successful,  the  patient  often  takes  a 
new  lease  of  life,  and  an  increase  of  from  forty  to  fifty  pounds 
in  weight  in  a  comparatively  short  time  is  frequently  observed. 

Congenital  Hypertrophic  Stenosis  of  the  Pylorus 

In  addition  to  the  above  forms  of  gastrectasis,  one  other 
should  be  mentioned, — congenital  hypertrophic  stenosis  of 
the  pylorus  with  secondary  gastrectasis. 

This  condition  manifests  itself  soon  after  birth,  by  the 
most  persistent  vomiting  and  dilatation  of  the  stomach.  A 
cure  is  to  be  expected  only  through  surgical  methods. 

[The  cHnical  course  of  congenital  hypertrophic  stenosis 
may  extend  over  a  period  of  many  years,  into  adult  life. 

The  most  characteristic  symptom  is  the  copious  vomiting 
of  food  eaten  several  days  previous. 

After  the  stomach  is  emptied  and  relieved  of  its  stagnating 
contents,  the  patient  is  in  good  health  and  without  any  gastric 
discomfort. 

These  attacks  of  vomiting  appear  at  more  or  less  regular 
intervals,  varying  in  point  of  time  from  a  few  days  to  several 
weeks  or  months. 

Corresponding  to  the  degree  of  stenosis  present,  there  is 
impairment  of  the  general  health  and  nutrition  of  the  patient. 

Lavage,  for  removing  the  stagnating  stomach-contents,  and 
the  administration  of  alkahes,  belladonna,  etc.,  for  the  hj^per- 
acidity  which  is  usually  present,  are  suitable  as  paUiative  treat- 
ment in  cases  presenting  infrequent  symptoms  of  the  disorder.] 


164  DISEASES  OF  THE  DIGESTIVE  CANAL  • 

CLINICAL    CASES 
r.   Cicatricial  Stenosis  of  the  Pylorus  with  Gastrectasis 

Case  1. — Emily  A.,  a  dairyman's  wife,  40  years  old,  suffered  from 
cicatricial  stenosis  of  the  pylorus  following  ulcer,  with  secondary  extreme 
dilatation  of  the  stomach  accompanied  by  symptoms  of  tetany.  The  oil- 
treatment  was  given,  which  was  followed  by  marked  improvement  in  a 
very  short  time.  Patient  gained  30  pounds  in  weight  in  two  months.  At 
the  end  of  treatment,  her  total  increase  in  weight  was  45  pounds. 

A  relative  cure  of  the  stenosis  resulted,  that  is,  the  patient  enjoyed 
good  health  and  suffered  no  inconvenience  while  she  continued  to  use  the 
stenosis-diet  and  the  oil-treatment. 

October  9,  1901 :  The  patient  had  previously  suffered  from  chlorosis, 
at  which  period  she  suffered  also  from  cardialgia  for  two  or  three  weeks  at 
a  time.  In  1894  she  had  vomited  blood,  with  melsena,  and  a  second  time  in 
1897.  Between  these  attacks  of  hsematemesis,  she  had  suffered  frequently 
from  cardialgia. 

At  that  time  an  operation  had  been  advised,  which  was  declined. 
The  patient  made  quite  marked  improvement  until  one  and  one-half  years 
ago,  since  which  time  she  had  copious  vomiting,  with  frequent  gastric  hemor- 
rhages. At  this  time  the  hemorrhages  were  occurring  about  every  eight 
to  ten  days,  and  for  the  past  eight  months  had  appeared  once  or  several 
times  daily.  There  were  extreme  emaciation,  oedema,  and  mild  symp- 
toms of  tetany.  Patient  was  urgently  advised  by  several  different 
physicians  to  undergo  operation,  but  refused.  The  stomach  was  washed 
out  several  times. 

Physical  Examination. — Patient  was  extremely  debilitated  and  as 
pale  as  wax.  She  weighed  only  81  pounds.  CEdema  of  the  lower  extremi- 
ties extended  to  the  calf  of  the  leg.  The  abdomen  was  very  much  relaxed 
and  strong  splashing  sounds  as  low  as  the  csecum  could  be  produced.  At 
the  right  of  the  median  line,  just  below  the  Hver,  in  the  region  of  the  gall- 
bladder, a  hard,  irregular  tumor  as  thick  as  the  thumb  was  palpable.  This 
was  thought  to  be  the  pylorus.  The  urine  contained  some  albumin.  The 
greater  curvature  of  the  stomach  extended  to  within  two  finger-breadths 
above  the  symphysis.  Enormous  quantities  of  material  were  obtained  from 
the  fasting  stomach,  which  contained  a  great  deal  of  free  acid,  sarcinte, 
and  yeast-cells.  During  the  lavage,  the  patient  had  a  slight  attack  of  tetany. 
She  was  put  on  absolute  rest  in  bed,  with  liquid  diet,  enemata,  and  the 
introduction  of  oil  following  the  lavage. 

October  11th:  Condition  of  the  patient  was  much  improved.  The 
gnawing  and  cramp-hke  pains  in  the  abdomen  had  entirely  disappeared. 
150  c.c.  of  oil  were  introduced. 

October  12th:  Patient  had  no  pain.  There  was  a  spontaneous,  soft, 
well-formed  stool.     There  were  no  eructations,   and  the  thirst  was  less; 


DISEASES  OF  THE  STOMACH  165 

no  gastric  discomfort  of  any  kind.  There  were  only  a  few  globules  of  oil 
obtained  from  the  stomach  in  the  morning  before  breakfast.  120  c.c.  of 
oil  were  introduced. 

October  13th:  Patient  had  another  slight  attack  of  tetany,  which 
was  less  severe. 

October  14th  to  17th:  The  patient  was  absolutely  free  from  pain, 
and  the  bowel  movements  were  regular.  Treatment  continued  and  dietary 
increased;   she  was  even  given  chicken,  wine  soup,  and  grits. 

October  23rd:  In  the  meantime,  the  patient  had  performed  the  lavage 
and  oil-treatment  at  home.  Evei'y  evening  before  retiring  she  had  drunk 
100  c.c.  of  oil.  Small  remnants  of  food  were  still  obtained  from  the  fasting 
stomach,  which  contained  sarcina?  and  yeast-cells.  No  other  attacks  of  tetany 
had  occurred.  The  abdomen  of  the  patient  was  soft,  a  slight  oedema  of  the 
legs  was  still  present,  and  only  traces  of  albumin  were  found  in  the  urine. 
Patient  was  allowed  to  eat  chicken,  filet,  and  puree  of  potatoes  with  butter. 

November  1st:  The  patient  weighed  104  pounds,  having  gained  17 
pounds  in  four  weeks.  CEdema  had  disappeared,  from  which  fact  we  know 
that  the  actual  increase  in  weight  was  greater  than  the  apparent.  The 
appetite  was  good.  The  greater  curvature  of  the  stomach  was  three  to 
four  finger-breadths  below  the  umbihcus.  The  right  border  of  the  stomach 
extended  10  cm.  beyond  the  median  line.  The  adiposis  panniculus  seemed 
considerably  thicker.  The  patient  had  no  repugnance  toward  the  continued 
use  of  the  oil.  Diet  now  consisted  of  tender  meats,  eggs,  milk,  cream,  and 
white  bread.    She  was  instructed  to  wash  out  her  stomach  every  second  day. 

November  8th:  Only  a  very  few  remnants  of  food, — consisting  mostly 
of  rice,  fruit-seeds,  etc., — were  obtained  from  the  fasting  stomach.  The 
general  health  of  the  patient  was  very  good. 

November  14th:  Sarcina;,  yeast-cells,  muscle-fibres,  and  other  rem- 
nants of  food  were  obtained  from  the  fasting  stomach.  Total  acidity  of  the 
gastric  juice,  105;   free  hydrochloric  acid,  68. 

December  11th:  Patient  weighed  111  pounds,  which  was  a  gain  of 
30  pounds  within  two  months.     She  was  allowed  to  leave  her  bed. 

January  3,  1902:  Greater  curvature  of  the  stomach  was  at  the  level 
of  the  umbihcus.     General  health  of  the  patient  was  good. 

December  17,  1902:  The  patient  weighed  126  pounds,  an  increase  of 
45  pounds.  Examination  showed  that  she  was  in  quite  good  condition, 
although  lavage  and  the  oil-treatment  are  necessary  from  time  to  time. 

2.  Traumatic  Ectasia 

Wm.  B.,  a  locksmith,  24  years  old,  had  had  previous  good  health  until 
he  received  a  severe  contusion  of  the  epigastrium  in  falling,  after  which  he 
suffered  from  symptoms  similar  to  those  of  ulcer,  followed  a  few  weeks 
later  by  typical  signs  of  gastrectasis  or  motor  insufficiency  of  the  second 
degree.     There  were  stagnation  of  the  ingesta,  copious  vomiting,  hyper- 


166  DISEASES  OF  THE  DIGESTIVE  CANAL 

chlorhydria,  a  fj:reat  number  of  sarcinrc  and  yeast-cells  in  the  contents 
obtained  from  the  fasting  stomach.  In  addition,  patient  suffered  from 
A-iolent  cramp-like  pain  in  the  epigastrium,  which  occurred  regularly  at  a 
certain  time  of  day,  and  was  usually  accompanied  by  vomiting.  He  was 
given  the  ordinary  treatment  for  dilatation  of  the  stomach, — lavage,  etc., — 
which  failed  to  give  any  imp!-o\'ement ;  but  instead,  he  continued  to  grow 
worse.  He  therefore  gave  up  lavage-treatment  and  sought  i-elief  by  arti- 
ficially producing  vomiting  by  irritating  the  palate  with  the  finger;  every 
three  or  four  days  he  would  produce  vomiting  as  thoroughly  as  possible  in 
this  way.  One  evening,  on  the  advice  of  an  acciuaintance,  after  having  thus 
emptied  his  stomach,  he  drank  a  glass  of  linseed  oil, — which  he  continued 
to  use  three  times  daily  for  several  weeks.  According  to  the  statement  of 
the  patient,  the  results  were  quite  astonishing.  Epigastralgia  ceased  im- 
mediatel}^  and  there  was  only  one  recurrence  of  vomiting.  After  several 
months  of  this  treatment,  the  patient  had  regained  normal  health.  He  was 
able  to  eat  all  kinds  of  food  without  any  discomfort  and  was  able  to  per- 
form the  same  heavy,  manual  labor  as  befoi'e  his  illness.  The  fasting  stomach 
was  always  found  to  be  free  from  food  and  contained  no  secretions.  The 
motor  insufficiency  was,  therefore,  completely  cured. 

3    Spastic  Stenoais  of  the  Pylorus 

Leopold  K.,  28  years  old,  an  engineer  from  Mexico,  had  suffered 
from  severe  epigastralgia  and  vomiting  of  blood  five  years  previous.  He 
had  been  given  the  "ulcer-cure,"  after  which  he  had  remained  well  for  two 
years.  He  then  suffered  from  a  recurrence  of  the  ulcer,  accompanied  by 
copious  vomiting,  heartburn,  and  cramp-like  pain,  occurring  especiall)^  at 
night.  Relief  from  epigastralgia  was  obtained  by  the  use  of  alkalies.  He 
was  repeatedly  advised  to  undergo  an  operation. 

Physical  Examination. —  Patient  was  extremely  emaciated,  his  weight 
being  only  106  pounds.  Food-remnants  and  sarcinjE  were  obtained  from  the 
fasting  stomach.    There  was  hyper  chlorhydria,  and  the  total  acidity  was  100. 

Treatment. — In  the  beginning  of  treatment,  the  stomach  was  washed 
out  daily,  then  two  or  three  times  a  week,  and  then  only  once.  One  hundred 
c.c.  of  olive  oil  were  given  every  morning.  At  the  beginning  of  treatment, 
the  patient  was  placed  on  an  absolute  liquid  diet,  and  later  on  semi-solids. 
Alkalies  with  atropine  were  given  after  meals.  One  month  later,  pain  and 
stagnation  had  entirely  disappeared,  and  the  patient  had  increased  in 
weight  to  120  pounds.    He  returned  to  Mexico  cured. 

4.  Operated  Case 

Mrs.  K.,  60  years  old,  had  suffered  from  gastric  ulcer  for  30  years. 
She  had  vomited  blood  several  times,  and  for  several  years  had  suffered 
from  food-stagnation  so  that  lavage  was  a  necessity.  In  this  case,  the  internal 
therapy,  including  the  oil-treatment,  was  unsuccessful.    She  was.  therefore, 


DISEASES  OF  THE  STOMACH  167 

advised  to  have  a  gastro-enterostomy,  which  resulted  in  a  complete  cure. 
At  the  operation  the  lumen  of  the  pylorus  was  found  to  be  contracted  to 
the  size  of  a  lead-pencil. 

Perigastritis 

Etiology. — As  has  been  shown  in  the  previous  chapter, 
perigastritis  results  chiefly  from  an  extension  of  ulceration 
of  the  mucosa  to  the  serous  coat  of  the  stomach-wall,  or  from 
acute  and  chronic  trauma  to  the  stomach  region,  or  finally 
from  inflammatory  processes  of  the  serous  coats  of  neighbor- 
ing organs, — especially  the  gall-bladcler  in  cholelithiasis  and 
empyema.  Peritoneal  adhesions  and  bands  are  formed  by 
these  inflammatory  processes,  just  as  in  diseases  of  the  uterus 
and  its  aclnexse.  In  ulcer  of  the  duodenum,  periduodenitis 
naturally  arises  in  the  same  way. 

Symptoms. — The  symptoms  of  perigastritis  may  be 
latent  for  years,  and  may  become  active  only  after  some 
sudden  twist  or  movement  of  the  body.  Sometimes,  however, 
an  exacerbation  of  the  inflammatory  process  occurs,  which 
causes  the  persistent,  boring,  stabbing  pain  in  the  epigastrium 
aggravated  by  movements  of  the  body  and  especially  by 
distention  of  the  abdominal  wall,  coughing,  sneezing,  pressing, 
lifting  of  heavy  weights,  or  bending  the  body  backwards.  In 
addition  to  these  symptoms,  forceful  downward  pressure  upon 
the  costal  cartilages  is,  according  to  Pariser,  especially  painful. 

Diagnosis. — A  diagnosis  of  perigastritis  can  never  be 
made  beyond  a  probability;  and  a  positive  diagnosis,  never. 
In  persons  who  have  been  injured,  symptoms  are  often  de- 
scribed which  may  be  attributable  to  perigastritis;  and  it  is 
necessary  to  add  that  such  a  history  w^ould  open  the  door 
freely  to  simulation  in  a  person  desiring  to  obtain  damages 
after  injury. 

Prognosis. — As  already  mentioned  in  the  previous  chap- 
ter, perigastritis  frequently  gives  rise  to  gastrectasis.  Bands 
of  adhesion  constrict  either  the  pylorus  or  the  duodenum, 
or  interfere  with  the  normal  peristaltic  movements  of  the 
pars  pylorica,  in  such  a  way  that  the  function  of  expelling  the 
contents  of  the  stomach  into  the  duodenum  is  interfered  with. 


168  DISEASES  OF  THE  DIGESTIVE  CANAL 

Treatment. — The  treatment  of  an  acute  exacerbation 
of  perigastritis  is  identical  with  that  of  acute  circumscribed 
peritonitis, — namel}'',  rest  in  bed,  hijuid  diet,  ice  and  opiates. 
If  the  course  of  the  disease,  in  chronic  perigastritis,  presents  no 
febrile  symptoms,  the  condition  should  be  treated  in  the  same 
manner  as  chronic  ulcer, — with  hot  applications,  rest  in  l)ed, 
liquid  diet,  and  bismuth.     (See  chapter  on  Gastric  Ulcer.) 

If  the  perigastritis  has  already  led  to  complications, — 
for  instance,  to  motor  insufficiency  and  secondary  dilatation 
of  the  stomach, — the  condition  should  be  treated  surgically. 

Hypersecretion 

(Gastrosuccorrhcea,  "Reichmann's  Disease") 

The  term  "hypersecretion"  was  introduced  into  the 
literature  by  Reichmann  in  1882,  as  a  clinical  entity.  By  this 
term  is  understood  the  pathological  condition  of  the  glands 
of  the  stomach  in  which  they  constantly  secrete  gastric  juice. 

In  this  affection,  considerable  amounts  of  gastric  juice, 
which  may  have  a  normal  acidity  or  a  hyperacidity,  can  be 
obtained  from  the  fasting  stomach  before  breakfast.  There 
is  no  uniformity  in  the  opinions  of  the  various  authors  as  to 
what  quantity  should  constitute  hypersecretion. 

Since  slight  amounts  of  gastric  juice  may  frequently  be 
obtained  from  the  stomach  of  healthy  persons,  it  is  better, — 
according  to  my  experience, — to  assume  the  presence  of  hyper- 
secretion only  when  at  least  20  to  30  c.c.  of  gastric  juice  are 
obtained  from  the  fasting  stomach. 

So  far  as  my  experience  goes,  hypersecretion  never  occurs 
from  a  purely  nervous  affection  of  the  stomach, — as  some 
authors  assume, — but  is  always  an  expression  of  an  acid 
gastritis  resulting  from  different  causes,  the  most  frequent 
factor  being  either  an  ulcer,  an  erosion,  a  fissure,  or  a  scar  at 
the  pylorus,  which  occasions  a  delay  in  the  emptying  of  the 
stomach,  and,  thereby,  a  constant  irritation  of  the  gastric 
glands.  It  is  for  this  reason  that  in  benign  stenosis  of  the 
pylorus  there  is  almost  always  a  hypersecretion,  which  is  the 
forerunner  of  motor  insufficiency  of  the  stomach. 


DISEASES  OF  THE  STOMACH  169 

The  next  most  important  etiological  factor  is  primary 
acid  gastritis  which  leads  to  hypersecretion.  The  following 
diagram  illustrates  clearly  the  origin  and  the  influence  of 
hypersecretion  in  gastric  pathology.     (Fig.  30.) 

In  this  diagram,  the  patient  is  represented  as  being  in 
good  health  at  the  point  "G;"  an  ulcer  of  the  pylorus  has 
developed  at  "U,"  which  at  "S"  is  represented  as  having 
given  rise  to  hypersecretion,  and  to  stagnation  at  ''St." 
Ectasia  is  the  last  stage  of  the  process,  represented  at  ''E," 
which,  when  rationally  treated,  leads  to  recovery. 

Fig.  30. 


Health  line. 


G.  G. 

Diagram  showing  the  development  and  course  of  hypersecretion. 

Hypersecretion,  therefore,  precedes  the  motor  insuffi- 
ciency of  the  stomach,  and  disappears  with  it  by  the  institution 
of  curative  measures. 

Hypersecretion  is  a  rudimentary  or  incomplete  dilatation  of 
the  stomach.  Periodical  hypersecretion  of  gastric  juice  is  almost 
always  a  symptom  of  tahes  dorsalis,  as  will  be  pointed  out  below. 

Symptoms. — The  subjective  symptoms  of  hypersecretion 
consist  of  burning,  boring,  and,  rarely,  cramp-like  pains  in 
the  epigastrium,  which  may  extend  to  the  throat, — all  of 
which  are  relieved  by  eating,  the  use  of  warm  drinks,  and 
especially  by  alkalies. 

Objectively,  there  occurs  vomiting  of  the  gastric  juice, 
which  is  often  so  sour  that  the  patient  feels  as  if  his  teeth 
were  covered  with  acid.  The  most  important  objective 
symptom,  however,  is  the  discovery  of  considerable  amounts, — 
from  30  c.c.  up  to  a  half-litre, — of  gastric  juice  in  the  fasting 
stomach.      The  total   acidity   of  the   gastric   juice  in  hyper- 


170  DISEASES  OF  THE  DIGESTIVE  CANAL 

secretion  amounts  to  from  70  to  110.  Bile  is  frequently  present 
and  mixed  with  the  gastric  juice. 

In  uncomplicated  hypersecretion,  there  are  neither  macro- 
scopical  nor  microscopical  evidences  of  food-remnants,  and 
sarcina3  are  absent.  Should  any  of  these  be  found  in  a  case  of 
hypersecretion,  the  assumption  is  safe  that  an  insufficiency 
already  exists  which  may  lead  to  dilatation  of  the  stomach. 

I  am  very  well  aware  that  different  authors  assume 
that  hyperchlorhydria  and  hypersecretion  are  primary  factors, 
and  that  pyloric  spasm,— which  is  the  immediate  cause  of 
the  irritation  of  the  mucous  membrane  of  the  stomach, — is 
secondary.  But  such  a  view  can  scarcely  be  correct,  for  the 
reason  that  after  the  cure  of  the  obstruction  at  the  pylorus,  by 
either  medical  or  surgical  treatment,  the  hypersecretion  spon- 
taneously disappears;  while,  on  the  other  hand,  very  many  cases 
of  hyperacidity  run  their  course  without  clinical  symptoms. 

In  the  cases  of  hypersecretion  which  are  the  immediate 
forerunners  of  motor  insufficiency,  starch-cells  are  sometimes 
obtained  from  the  fasting  stomach  early  in  the  morning; 
while  if  meat-fibres  are  entirely  absent,  the  clinician  should 
not  be  surprised,  because  the  proteid  foods  may  have  been 
digested  during  the  night  by  the  action  of  the  hyperpeptic 
gastric  juice. 

Diagnosis. — An  exact  diagnosis  of  hypersecretion  is 
possible  only  by  the  use  of  the  stomach-tube  and  the  exami- 
nation of  the  fasting  stomach.  If  considerable  amounts  of 
gastric  juice  are  constantly  present,  in  which  there  is  no  ad- 
mixture of  food-remnants,  the  diagnosis  is  positive.  The 
subjective  symptomatology  frecjuently  leads  to  confusion 
with  such  associated  conditions  as  ulcer,  fissures,  and  erosions. 

In  the  differential  diagnosis,  the  physician  should  always 
eliminate  the  periodically  occurring  gastric  crises  of  tabes 
dorsalis,  and  the  vomiting  which  is  frequently  associated 
with  migraine. 

Treatment. — The  treatment  of  hypersecretion  should 
be  directed  exclusively  toward  the  primary  disease.  The 
therapeutic    procedures    instituted,    therefore,    depend  upon 


DISEASES  OF  THE  STOMACH  171 

whether  an  ulcer  or  a  hyperacid  alcohoHc  gastritis,  etc.,  is 
the  cause  of  the  trouble. 

A  tablespoonful  of  olive  or  almond  oil  should  be  given 
three  times  daily,  or  the  milk  of  almonds  (see  page  124)  may 
be  substituted  before  meals,  if  the  condition  is  complicated  by 
pylorospasm.  Alkalies  should  be  administered  after  eating. 
The  diet  should  be  semi-lic|uicl  and  rich  in  fats. 

If  the  primary  lesion  is  an  acid  gastritis  with  erosions  of 
the  pyloric  mucosa,  large  doses  of  Carlsbad  or  Vichy  water 
should  be  given  before  meals,  or  the  patient  should  be  sent 
to  one  of  these  watering-places.  Gormands  and  heavy  smokers 
belong  especially  in  this  category  of  patients. 

The  mastication  tablets  of  Bergmann  or  Belloc  may  be 
used  symptomatically  to  great  advantage,  just  as  in  similar 
lesions  of  the  stomach. 

The  treatment  of  hypersecretion  is  of  especial  importance 
as  a  prophylactic  agent  against  gastrectasis,  since  we  must 
always  consider  hypersecretion  as  a  preliminary  or  initial 
stage  of  dilatation. 

Since  every  case  of  hypersecretion  is  the  result  of  an 
anatomical  lesion  of  the  stomach,  and  should  never  be  con- 
sidered a  nervous  affection,  anti-nervous  treatment  is  useless. 

CLINICAL    CASES 
Acid  Gastritis 

Case  1. — Maurice  K.,  a  merchant,  50  years  old,  had  indulged  in  the 
use  of  fatty  foods,  smoking,  and  beer-drinking.  His  appetite  was  very  good, 
but  he  had  begun  to  be  afraid  to  eat  because  of  a  burning  pain  in  the  epi- 
gastrium several  hours  after  eating,  vi^hich  had  occurred  regularly  for  the 
past  two  or  three  months.  Pyrosis  was  frequent.  He  was  a  very  strong, 
obese  man.  In  every  examination  of  the  fasting  stomach,  30  to  40  c.c.  of 
secretion  were  obtained,  the  total  acidity  of  which  was  80  to  100. 

The  patient  was  cured  at  Carlsbad. 

CavSE  2. — Heinrich  B.,  a  brewer,  30  years  old,  presented  the  same 
etiological  and  clinical  course  as  in  Case  1,  hj^^ersecretion  resulting  from 
a  relative  stenosis  of  the  pjdorus. 

(For  other  clinical  cases,  the  reader  is  referred  to  case-histories  described 
at  the  end  of  the  chapter  on  Gastrectasia,  in  the  course  of  which  the  symptom 
of  hypersecretion  is  frequently  mentioned.) 


17  >  DISEASES  OF  THE  DIGESTIVE  CANAL 

Hy  perchlorhyd  ria 

Hj'perchlorhyclria  and  hyperst'cri'tion  are  not  the  same. 

Hypersecretion  indicates  an  increase  in  the  secretion  of 
gastric  juice  of  normal  acidity,  while  hyperchlorhydria  is 
the  secretion  of  an  excessively  acid  gastric  juice.* 

In  hypersecretion,  the  test-breakfast  is  alwaj's  found  to 
be  well  digested  and  of  a  fluid  consistency,  or  nearly  so;  on  the 
other  hand,  in  hyperchlorhydria,  the  test-breakfast  is  only 
moderately  well  digested  and  rather  semi-solid  in  consistency. 

As  a  matter  of  course,  both  of  the  above-mentioned 
anomalies  of  secretion  may  occur  at  the  same  time. 

Although,  as  we  have  seen  in  the  foregoing  chapters, 
hj^peracidity  is  not  a  disease  sui  generis,  being  merely  a 
symptom  of  various  affections,  yet  it  is  so  frequently  and 
prominently  associated  with  disorders  of  the  stomach  and 
intestine  that  it  is  deserving  of  special  consideration  in  a 
practical  work  of  this  kind. 

According  to  its  etiology,  there  are  four  different  forms 
of  hyperacidity  that  clinically  may  be  very  well  classified, 
diagnosed,  and  causally  treated. 

These  four  forms  are:  (1)  hyperacidity  in  acid  gastritis;  (2) 
hyperacidity  in  ulcer  and  stenosis  of  pylorus;  (3)  hyperacidity 
in  neurasthenia;   (4)  hyperacidity  in  chronic  constipation. 

The  first  and  second  forms  are  the  expression  of 
organic,  anatomical  diseases;  while  the  third  and  fourth 
are  expressions  of    functional    affections. 

The  physician  will  be  able  to  differentiate  the  various 
forms  by  the  following  characteristics: 

1.   Hyperacidity  Occurring  in  Acid  Gastritis 
The  test-breakfast  has  a  total  acidity  of  from  70  to  120 
and  is  of  a  thick,  pulpy  consistency,  while  frequently  there 
is  a  diminished  secretion  of  gastric  juice. 

*According  to  the  most  recent  examinations  of  the  Pawlow's  school,  it 
appears  that  the  concentration  of  the  gastric  juice  is  always  the  same,  and  its 
total  acidity  amoimts  to  about  120.  The  acidity,  therefore,  depends  only  upon 
the  number  of  cubic  centimetres  secreted.  In  case  "A,"  for  instance,  there  are 
secreted  in  one  hour  200  c.c.  while  in  case  "B,"  only  100,  etc. 


DISEASES  OF  THE  STOMACH  173 

The  anamnesis  of  such  patients, — and  this  is  of  the  great- 
est importance, — shows  a  history  of  abuse  of  tobacco,  wine, 
beer,  and  excesses  in  eating. 

As  a  rule,  the  patients  will  be  found  to  have  felt  sub- 
jective pressure  and  discomfort  after  eating  heavy  foods; 
but  in  cases  where  the  formation  of  erosions  of  the  mucosa 
has  already  occurred,  the  patients  suffer  from  burning  pain 
in  the  epigastrium  two  or  three  hours  after  eating,  which  is 
relieved  by  again  taking  food  into  the  stomach. 

In  individual  cases,,  if  the  erosions  are  located  in  the 
pylorus,  the  pain  is  of  a  cramp-like  character,  the  so-called 
"epigastralgia,"  which,  however,  rarely  occurs  immediately 
after  eating,  but  usually  several  hours  later,  especially  if  the 
patients  have  indulged  in  errors  in  diet,  beer-drinking  or 
heavy  smoking.  Besides  the  burning  in  the  region  of  the 
stomach,  pyrosis  is  very  frequent. 

Obese  and  strongly-built  individuals  with  hearty  appe- 
tites are  usually  predisposed  to  this  disease. 

2.  Hyperacidity  in  Ulcer  and  Stenosis  of  the  Pylorus 

In  these  affections,  the  stasis  of  the  ingesta  causes  an 
irritation  of  the  gastric  glands  and,  thereby,  an  increase  in 
the  amount  of  gastric  juice  secreted,  i.e.,  hypersecretion  and 
hyperchlorhydria  occur. 

Concerning  the  symptoms  of  this  form  of  hyperchlor- 
hydria, the  reader  is  referred  to  the  chapters  on  Ulcer  of  the 
Stomach  and  Gastrectasis. 

The  therapy  likewise  needs  no  further  consideration. 

Anatomical  changes  of  the  gastric  glands,  consisting  of 
hypertrophy  of  the  acid  cells  and  atrophy  of  the  chief  cells, 
are  present  in  both  of  these  forms  of  hyperchlorhydria. 

In  acid  gastritis,  the  glands  become  irritated  from  excesses 
in  eating;  while  in  ulcer  and  stenosis  of  the  pylorus,  the 
hyperchlorhydria  is  the  result  of  the  disturbance  of  the  motility 
of  the  stomach. 

In  the  first  form,  the  hyperchlorhydria  is  primary;  and 
erosions,  should  they  occur,  are  secondary. 


174  DISEASES  OF  THE  DIGESTIVE  CANAL 

All  other  cases  of  hyperchlorhydria  that  can  be  objec- 
tivel}'  diagnosticated  are  of  a  functional  nature. 

They  may  be  clinically  differentiated  from  the  hyper- 
chlorhydria of  organic  disease  by  the  absence  of  actual  pain. 

The  chnical  course  of  such  is  either  entirely  without 
symptoms,  and  hyperchlorhydria  is  only  discovered  as  an 
accidental  or  associated  condition;  or  they  produce,  at  most, 
only  mild  pressure  in  the  stomach,  or  heartburn,  discomfort 
and  feeling  of  fulness  in  the  epigastrium. 

3.  Hyperchlorhydria  Occurring  in  Neurasthenia 

This  form  of  hyperchlorhydria  is  found  most  commonly 
in  neuropathically  disposed  individuals,  and  especially  in 
such  as  have  the  habitus  enteropticus. 

The  s3^mptoms  consist  of  pressure  in  the  stomach  after 
heavy  meals,  especially  if  the  patient  has  not  had  the  neces- 
sary amount  of  rest. 

In  this  form  of  hyperchlorhydria,  actual  pain  never  occurs. 

The  treatment  should  be  directed  toward  the  removal  of 
the  primary  disease,  therefore  should  combat  the  general 
nervous  condition  of  the  patient.  A  full  discussion  of  the 
details  of  the  therapy  will  be  found  in  the  section  on  Func- 
tional Diseases  of  the  Stomach. 

4.  Hyperchlorhydria  Occurring  in  Chronic  Constipation 

This  exists  very  frequently  without  causing  the  patient 
any  discomfort,  or  there  is  only  a  feeling  of  unpleasantness 
and   fulness  after  eating. 

This  form  of  hyperacidity  is  also  of  a  functional  nature, 
and  disappears  as  soon  as  chronic  constipation  has  been  cured 
by  proper  treatment. 

The  cause  of  hyperacidity  in  chronic  constipation  is  not 
quite  clear.  One  factor  may  be  that  the  mucous  membrane 
of  the  stomach  is  irritated  by  the  abuse  of  purgatives  and 
laxatives;  and  another  cause  may  be  that  when  there  is  a 
stasis  of  the  intestinal  contents,  the  peristaltic  action  of  the 
musculature  of  the  stomach  is  similarly  affected. 


DISEASES  OF  THE  STOmIcH  175 

According  to  the  above  consideration  of  hyperchlorhydria, 
it  is  evident  that  there  is  as  httle  uniformity  in  the  etiology 
of  the  different  forms  of  the  disease  as  in  its  treatment. 

It  is,  therefore,  illogical  for  some  authors  to  enthusiastic- 
ally recommend  a  meat-diet  for  hyperchlorhydria,  and  for 
others  to  insist  upon  the  necessity  of  a  vegetarian  diet.  Nor 
is  it  to  be  wondered  at  that  under  either  of  such  dietetic 
regimes  there  occur  as  many  absolute  failures  as  successes  in 
the  treatment;  for  the  treatment  of  hyperchlorhydria  must 
always  be  planned  according  to  its  etiology. 

Besides  the  four  forms  of  hyperchlorhydria  already 
mentioned,  there  is  still  a  fifth,  which  occurs  acutely  as  the 
so-called  "  Gastroxynsis, "  of  Rossbach,  which  begins  suddenly 
and  continues  from  one  to  several  days,  with  an  extraordinary 
increase  in  the  secretion  of  gastric  juice,  accompanied  by 
boring  pains   and   vomiting. 

It  is  probable  that  in  most  of  these  cases  we  have  to  do 
with  gastric  crises  of  tabes  dorsalis ;  and  it  should  be  pointed 
out  here  that  the  gastric  crises  may  occur  as  the  first  symptom 
of  tabes.  I  saw  such  a  case  in  a  man  twenty-three  years  old, 
three  years  after  syphilitic  infection. 

The  transient  duration  of  hyperchlorhydria  in  these 
cases  prevents  the  physician  from  confusing  the  condition 
with  ulcer  of  the  pylorus,  in  which  pain  also  occurs  periodi- 
cally; but  in  this  instance  each  period  has  a  duration  of 
several  weeks,  when  the  pain  occurs  regularly  at  a  certain 
time  after  eating. 

Hyperchlorhydria  continues  throughout  the  entire  life 
of  some  individuals.  Indeed  in  some  families  it  is  hereditary, 
— nearly  all  the  members  being  affected,  and  is  especially 
frequent  in  families  where  obesity  is  a  characteristic. 

Prognosis. — The  prognosis  is  very  good  in  the  functional 
forms  of  hyperchlorhydria. 

The  prognosis  is  generally  favorable  if  the  patient  is 
able  and  willing  to  confine  himself  to  hygienic  living,  to 
forego  smoking,  drinking,  and  excessive  eating,  and  to  wear 
suitable  clothing  which  will  not  constrict  the  epigastrium,  etc. 


176  DISEASES  OF  THE  DIGESTIVE  CANAL 

Hyperclilorhydria,  if  it  has  existed  for  several  years,  grad- 
ually terminates  in  normal  acidity  and  finally  in  sub-acidity, 
of  the  gastric  juice;  this  is  especially  the  case  in  acid  gastritis. 

I  have  personally  observed  patients  during  the  evolution 
of  this  disease,  in  whom  the  total  acidity  was  at  first  80, 
then  ()0,  and  later  as  low  as  40. 

In  stenosis  of  the  pylorus,  the  hyperacidity  gradually 
decreases  after  the  obstruction  has  been  removed. 

Treatment. — The  method  of  treatment  in  a  case  of  hyper- 
chlorhydria  should  always  depend  upon  the  cause. 

In  hyperacidity  caused  by  acid  gastritis  and  ulcer,  there- 
fore, the  treatment  should  be  local;  while  the  therapeutic 
measures  in  hyperchlorhydria  occurring  in  neurasthenia  and 
constipation  should  always  be  general. 

The  physician  should  prescribe  a  lacto-vegetable  diet  in  the 
first  two  forms ;  in  the  neurasthenic  form,  a  mixed  diet,  combined 
with  forced  feeding;  and  in  the  last  form,  a  vegetarian  diet, — 
in  order  to  obtain  regular  spontaneous  evacuations  of  the  bowels. 

CLINICAL    CASES 
Histories  of   patients  illustrating  the  first  two  forms  of   hyperchlor- 
hydria will  be  found  at  the  end  of  the  chapters  on  Gastritis  and  Ulcer  of 
the  Stomach,  respectively. 

1.  Nervous  Hyperacidity 

Case  1. — Ernst  E.,  a  teacher,  61  years  old,  had  suffered  discomfort 
and  pressui-e  in  the  epigastrium  for  six  months,  after  eating.  The  appetite 
was  poor.  Patient  had  an  aversion  against  fatty  foods.  He  presented  the 
typical  fear-phenomena  of  neurasthenia.  The  bowels  were  sluggish.  The 
patient  had  had  nervous  shocks  caused  by  two  deaths  in  the  family,  and  he 
slept  poorly.    Treatment  in  a  sanatorium  had  been  unsuccessful. 

Patient  was  given  bromide,  digitalis,  asafetida,  and  iron,  without 
improvement.     He  lost  22  pounds  in  weight.     He  had  suicidal  intentions. 

Physical  examination  of  the  patient  was  negative.  There  was  no  sugar 
in  the  urine.  Examination  of  the  stomach  showed  the  presence  of  hyperchlor- 
hydria.   The  total  acidity  was  80.    The  motility  of  the  stomach  was  normal. 

Treatment  consisted  in  the  rest-  and  fattening-cure  and  the  use  of  bit- 
ters. He  gained  fourteen  pounds  in  weight.  Improvement  was  very  slow, 
and  not  until  three  and  one-half  years  later  was  he  quite  cured. 

For  clinical  cases  illustrating  hyperchlorhydria  in  chronic  constipation, 
see  the  section  on  Diseases  of  the  Intestine. 


DISEASES  OF  THE  STOMACH  177 

FUNCTIONAL  DISEASES  OF  THE  STOMACH 

General  Remarks. — It  should  not  be  concluded,  from  the 
considerable  space  devoted  to  the  organic  diseases,  that 
they  necessarily  exceed,  in  their  frequency,  the  functional 
diseases  of  the  stomach.  On  the  contrary,  the  functional 
diseases  deserve  equal  space  and  interest  in  gastric  pathology. 

We  include,  under  functional  or  nervous  dyspepsias,  all 
those  diseases  in  which  no  pathological  anatomical  change  of 
the  stomach  is  demonstrable;  in  which,  therefore,  the  organ 
is  diseased  only  in  the  pathological-physiological  sense. 

Although  functional  diseases  of  the  stomach  are  often 
very  stubborn  in  yielding  to  treatment,  still  by  suitable  meas- 
ures they  may  usually  be  brought  to  complete  cure  and  recovery. 

The  successful  results  from  the  application  of  thera- 
peutic measures  in  the  diseases  of  the  digestive  tract  depend 
upon  the  physician's  being  able  to  classify  correctly  each 
individual  case  in  either  one  or  the  other  group  of  digestive 
diseases, — o  rganic  or  functional  , — and  when  a 
combination  of  both  exists,  to  determine  which  of  the  two  is 
primary,  in  order  that  he  may  know  where  to  begin  the  appli- 
cation of  the  therapeutic  measures. 

It  is  clear  that  frequently  a  patient  suffering  from  an  organic  disease 
of  the  stomach. — for  instance,  ulcer, — will  if  neuropathically  inclined  pre- 
sent evidences  of  nervous  dyspepsia  in  addition  to  the  ulcer-symptoms. 

This  occurs  with  especial  frequency,  as  we  shall  see  below,  in  diseases 
of  the  intestines. 

The  opposite  is  also  true, — that  a  functional  affection, — for  instance, 
nervous  anorexia, — may  lead  to  an  organic  disease  of  the  stomach  in  con- 
sequence of  the  disturbances  induced  by  malnutrition. 

Etiology. — The  factors  which  favor  the  development  of 
a  functional  disease  of  the  stomach  are  both  inherited  and 
acquired. 

Among  the  inherited  tendencies  is  the  habitus,  which, 
according  to  the  admirable  examinations  of  Stiller,  has  been 
designated  as  the  so-called  habitus  enter  opticus,  or  asthenia 
universalis  congenita.     This  habitus,  which  plays  a  prominent 

12 


178  DISEASES  OF  THE  DIGESTIVE  CANAL 

part  in  the  diagnosis  of  the  diseases  of  the  stomach  and  intes- 
tine, has  .ah-eady  received  sufficient  and  appreciative  mention 
in  the  introduction. 

In  habitus  cntcropticus,  all  of  the  abdominal  organs  assume  a  position 
more  nearly  longitudinal  than  transverse, — especially  the  stomach,  which 
while  normal  lies  almost  diagonally  from  left  to  right,  but  in  habitus  entcrop- 
ticus  takes  an  almost  vertical  position. 

It  is  easy  to  understand  that  the  abdominal  organs  in  enteroptosis 
assume  a  lower  position  if  the  patient  becomes  emaciated  or  the  abdominal 
walls  are  relaxed. 

So  long  as  persons  with  habitus  enteropticus  are  well  nourished,  or  are 
obese,  and  in  women  so  long  as  the  abdominal  walls  are  not  weakened  and 
relaxed  by  pregnancy,  no  symj^toms  are  caused  by  the  presence  of  habitus 
enteropticus.  It  is  not  until  some  cause, — such  as  loss  of  appetite  or  some 
nervous  affection, — lowers  the  nutrition  of  an  enteroptotic  individual,  that 
the  fully-developed  sym^Dtoms  of  enteroptosis  appear. 

Enteroptosis  is,  therefore,  a  disease,  while  habitus  enteropticus  repre- 
sents only  the  predisposition. 

If  the  physician  is  in  doubt  in  a  given  case  as  to  whether  the 
patient  is  suffering  from  an  organic  or  a  functional  dyspepsia, 
he  should,  as  a  rule,  determine  the  habitus  of  the  patient. 
This  will  very  often  prevent  his  being  misled  in  the  diagnosis. 

Organic  diseases, — such  as  ulcer,  gastritis,  etc.,  usually 
occur  in  individuals  with  normal  habitus. 

Functional  dyspepsia,  on  the  other  hand,  occurs  almost 
without  exception  in  persons  with  the  habitus  enteropticus. 

This  generalization  does  not  debar  the  fact  that  the 
reverse  of  these  general  principles  is  sometimes  true. 

All  conditions  that  are  capable  of  weakening  the  consti- 
tution of  the  patient,  affecting  his  entire  muscular  and  ner- 
vous system,  and,  in  fact,  all  factors  leading  to  neurasthenia, — 
hysteria,  anemia,  or  malnutrition, — predispose  the  individual 
to  functional  diseases  of  the  stomach.  Tuberculosis,  sj'phihs, 
and  insufficient  nourishment,  especially  in  persons  who  are 
physically  or  mentally  over-worked,  lead  to  anaemia  and  mal- 
nutrition, which  may  also  simultaneously  cause  neurasthenia. 

The  nervous  system  is  also  debilitated  through  excesses 
in  Baccho  et  Venere,  from  sexual  abuses  of  any  kind,  and 
especially  from  masturbation. 


DISEASES  OF  THE  STOMACH  179 

Emotional  strain  from  business  and  family  troubles, 
depression,  worry,  disappointment  in  love,  continuous  excite- 
ment, death  of  relatives,  and  fear  of  contagion  in  caring  for 
the  sick, — all  play  an  etiological  role  in  the  functional  dys- 
pepsias. It  is  not  possible  to  mention  in  detail  all  of  the 
factors  that  weaken  the  general  health  of  the  individual. 

Only  one  other  factor  will  be  emphasized;  that  is, 
trauma,  which  is  sometimes  the  cause  of  a  functional  stomach 
affection  (traumatic  neuroses). 

If  any  of  the  above  factors  have  already  caused  a  disturb- 
ance of  the  functions  of  the  stomach,  this  in  itself  will  result 
in  a  further  aggravation  of  the  trouble,  for  the  reason  that 
the  patient  eats  less,  and  is  therefore  insufficiently  nourished, 
which  still  further  depletes  his  general  force  and  vitality. 

This  fact  best  explains  the  reason  why  such  patients  are 
irrationally  put  on  a  limited  diet  of  liquids  for  years, — -the 
attending  physician  mistaking  the  functional  dyspepsia  for 
one  of  an  organic  nature. 

Diagnosis. — The  diagnosis  of  functional  diseases  of  the 
stomach  is,  as  a  rule,  easy.  The  physician  is,  in  most  cases, 
able  to  differentiate  these  troubles  from  organic  diseases  by 
the  anamnesis,  as  has  been  shown  in  detail  in  the  description 
of  the  diagnosis  of  ulcer,  carcinoma,  and  catarrh  of  the  stomach. 

The  fact  that  in  functional  diseases  of  the  stomach  actual 
pain  scarcely  ever  occurs,  is  of  the  greatest  practical  import- 
ance in  the  diagnosis. 

The  symptoms  are,  instead,  only  general  dyspeptic 
disturbances,  a  feeling  of  fulness  in  the  stomach,  loss  of 
appetite  or  rapid  satiation  of  hunger,  eructation,  pyrosis, 
regurgitation,  salivation,  and  constipation, — with  general 
lassitude,  weakness  and  lack  of  desire  to  work. 

Prognosis. — The  prognosis  of  a  functional  disease  of  the 
stomach  is  in  itself  good.  Cure  always  results  if  the  disease 
which  caused  the  dyspeptic  symptoms  can  be  removed. 

Unfortunately  this  is  often  impossible,  because  in  the 
struggle  for  existence  many  patients  lack  the  time  and  money 
to  afford  themselves  the  necessary  rest  and  care. 


180  DISEASES  OF  THE  DICxESTIVE  CANAL 

It  need  scarcely  be  mentioned  that  very  frequently  it  is 
absolutely  essential  to  a  cure,  that  the  patient  be  sent  away 
for  change  of  scene  and  climate  in  order  that  his  mind  may  be 
diverted  by  new  surroundings.  If  ho  is  able  to  fulfil  these 
requirements  for  a  sufficient  length  of  time,  a  cure  generally 
results.  But  it  is  to  be  expected  that  relapses  will  frequently 
occur  if  the  patient  resumes  his  former  habits  of  living,  because 
like  causes  produce  like  effects. 

Treatment, — Treatment  should  be  almost  exclusively 
directed  to  the  removal  of  the  primary  disease,  and  should 
be,  therefore,  general,  in  contradistinction  to  the  treatment 
of  organic  disease  of  the  stomach,  which  is  local  and  directed 
to  the  stomach  itself. 

It  is  often  very  difficult  to  distinguish  the  different  vari- 
eties of  functional  dyspepsia,  in  none  of  which  are  there 
pathological  alterations  of  the  gastric  mucosa.  They  often 
merge  gradually  into  one  another  and,  in  general,  have  many 
symptoms  in  common. 

The  following  classification,  which  is  arranged  according 
to  etiological  principles,  has  served  me  so  well  in  practice  that 
I  do  not  hesitate  to  retain  it  in  a  book  which  is  designed  to 
serve  as  a  guide  to  the  general  practitioner,  although  I  am 
well  aware  that  such  a  classification  is  not  in  accordance  with 
that  given  in  most  of  the  text-books  on  stomach  diseases. 

AnaBmic=Gastroptotic  Dyspepsia 

(Atonia,  or  Myasthenia  Ventriculi,  Mechanical  Insufficiency  of  the 
First  Degree,  Nervous  Dyspepsia) 

As  the  name  indicates,  we  understand  anaemic-gastroptotic 
dyspepsia  to  be  that  affection  of  the  stomach  in  which  the  most 
characteristic  symptom  is  the  low  position  of  this  organ  in  a 
poorly-nourished  individual. 

Since  this  condition  has  been  discussed  in  the  Introduc- 
tion, I  will  here  briefly  cover  only  the  etiological  points. 

The  predisposition  to  this  form  of  dyspepsia  is  either  a 
congenital  hahitns  enter oyticus,  or  an  acquired  enteroptosis 
following  pregnancy;    while  the  exciting  causes  of  the  disease 


DISEASES  OF  THE  STOMACH  181 

may  be  any  condition  that  loads  to  anscmia,  neurasthenia,  or 
malnutrition  of  the  individual. 

Gastroptotic  dyspepsia,  commonly  known  as  atony,  is 
extraordinarily  frequent,  being  perhaps  the  most  common 
disorder  of  the  stomach. 

Its  accurate  recognition,  therefore,  is  of  great  practical 
importance.  It  very  frequently  happens  that  not  only  the 
laity,  but  physicians  also  classify  this  very  ordinary  affection 
erroneously  under  the  title,  ''chronic  gastritis."  This  explains 
why  it  is  that  so  many  patients  suffering  from  functional 
disorders  of  the  stomach  are  not  cured,  and  why  it  is  that 
they  ultimately  fall  into  the  hands  of  "neuropaths,"  who, 
by  the  establishment  of  hygienic  measures  and  by  the  use  of 
hydrotherapy,  very  often  effect  brilhant  cures. 

Symptomatology. — The  symptoms  of  the  disease  are 
divided  into    subjective    and    objective. 

The  former  are  far  more  characteristic  than  the  latter, 
so  that  it  is  usually  possible  to  make  a  correct  diagnosis  if 
the  anamnesis  is  obtained  with  accuracy  and  care. 

Subjective  Symptoms. — Subjective  symptoms  consist  of 
all  kinds  of  dyspeptic  disturbances,  but  especially  of  pressure 
in  the  stomach  after  heavy  meals  and,  in  severe  cases,  even 
after  a  plate  of  soup  or  a  glass  of  milk.  Other  symptoms  are 
a  feeling  of  fulness  and  distention  in  the  epigastrium,  rapid 
satiation  of  appetite,  or  anorexia,  gaseous  and  acid  eructations, 
regurgitation  of  food  a  short  time  after  eating,  sluggish  bowels, 
water-brash  and  nausea,  general  lassitude  and  distaste  for 
work,  especially  after  meals. 

On  the  other  hand,  actual  pains  never  occur  in  uncom- 
plicated anaemic-gastroptotic  dyspepsia,  as  has  already  been 
stated  in  the  discussion  of  Ulcer  and  Stenosis. 

Objective  Symptoms. — The  objective  symptoms  are  general 
emaciation  and  anaemia,  in  addition  to  the  presence  of  habitus 
enteropticus,  evidenced  by  an  acute  costal  angle,  the  long, 
narrow  thorax,  and  fluctuation  of  both  tenth  costal  ribs. 

The  abdomen  is  relaxed,  and  the  splashing  sounds  are 
easily  produced. 


182  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  lower  border  of  the  stomach  frcquentl}'  Ucs  at  the 
level  of  the  umbilicus,  or  two  or  three  finger-breadths  below  it. 
Frequenth',  in  women  who  have  borne  children,  the  greater 
curvature  extends  a  hand-breadth  ])eh)w  tlie  umbilicus,  or 
even  to  the  sj'mphysis  pubis.  The  position  of  the  greater 
curvature  is  easily  determined  by  Obrastzow's  method, 
which  has  been  described  in  detail  in  the  General  Section. 
If  there  is  not  a  sufficient  amount  of  fluid  in  the  patient's 
stomach  at  the  time  of  examination,  the  ph3^sician  should 
have  him  drink  one  or  two  glasses  of  water  and  should  then 
determine  the  location  of  the  fluid  by  palpatory  percussion. 

The  various  ingenious  methods  for  ascertaining  the  position  of  the 
greater  curvature, — such  as  the  carbon  dioxide  distention  of  the  stomach  by 
the  use  of  effervescent  powders,  and  inflating  the  stomach  with  air  by  means 
of  the  stomach-tube  and  a  rubber  bulb,  and  the  illumination  of  the  stomach 
by  Einhorn's  diaphane, — are  not  essential  in  general  practice,  and  are  besides 
very  annoying  to  the  patient.  A  detailed  description  of  these  methods  may 
be  found  in  any  text-book  on  Diseases  of  the  Stomach  and  Intestine. 

In  addition  to  gastroptosis,  there  is  generally  a  ptosis  of 
the  transverse  colon  and  a  dislocated  right  kidney, — the 
left  kidney  being  less  frequently  movable. 

The  examination  of  the  stomach  with  the  stomach-tube 
gives  the  following  findings: 

The  fasting  stomach  is  alwaj's  found  entirely  empty 
the  morning  after  the  test-supper,  or  at  most  contains  only 
a  few  cubic  centimetres  of  gastric  juice  mixed  with  mucus 
and  epithelium  from  the  mouth,  oesophagus  and  bronchi. 

Should  remnants  of  food  be  found,  contrary  to  the  expec- 
tation of  the  physician,  atony  may  be  excluded  from  the  diag- 
nosis, the  condition  being  more  probably  that  of  gastrectasis. 

An  hour  after  the  Boas-Ewald  test-breakfast,  the  stomach- 
contents  will  be  found  well  digested,  with  a  total  acidity  of 
from  40  to  65,  although  transient  hjq^eracidity  and  sub- 
aciclity  also  sometimes  occur, — to  which,  however,  no  great 
importance  should  be  given. 

It  would  be  incorrect  to  assume  the  presence  of  a  gas- 
tritis, should  the  total  acidity  amount  to  only  20  or  30,  if 


DISEASES  OF  THE  STOMACH  183 

otherwise  the  clinical  symptoms  of  the  case  were  those  of 
ansemic-gastroptotic  dyspepsia. 

The  remnant-test  of  Mathieu-Remond  (see  page  35) 
usually  amounts  to  from  220  to  270  c.c.  one  hour  after  the 
test-meal.  Although  this  exceeds  the  normal,  it  is  as  likely  to 
be  due  to  an  increase  of  the  gastric  secretions  as  to  impair- 
ment of  the  motor  powers  of  the  stomach. 

Seven  hours  after  the  Riegel  test-dinner  (see  page  35), 
the  stomach  will  usually  be  found  empty. 

In  cases,  however,  of  extreme  physical  debility,  some  of 
the  test-dinner  may  still  be  present  in  the  stomach  seven 
hours  after  eating.  These  cases,  however,  do  not  differ  in 
any  other  factor  from  the  usual  ansemic-gastroptotic  dyspepsia. 

It  has  been  thought  necessary  by  some  to  designate  such 
cases  as  motor  insufSciency  of  the  first  degree,  or  atony. 

The  authors  who  share  this  view  ascribe  the  delay  in  the 
expulsion  of  food  into  the  duodenum  to  a  primary  muscular 
weakness  of  the  stomach.  I  am  of  the  opinion  that  the  find- 
ing of  small  remnants  of  food  seven  hours  after  the  test- 
dinner  is  as  frequently  the  result  of  excessive  secretion  of  the 
gastric  juice,  and  that  it  is  occasionally  caused  by  diminished 
innervation  of  the  musculature  of  the  stomach. 

That  the  authors  who  consider  the  cause  of  the  trouble  to  be  a  primary 
muscular  weakness  of  the  stomach  cannot  be  in  the  right,  is  best  proven 
by  the  therapeutic  resuhs  of  forced  feeding  in  this  affection. 

If  this  theory  were  correct,  such  patients  would  suffer  from  gastrec- 
tasis  or  motor  insufficiency  of  the  second  degree  when  their  stomachs  were 
excessively  overloaded  by  the  forced  feeding.  Since  this  is  never  the  case, 
but  on  the  contrary,  such  patients  recover  their  health  through  the  forced 
feeding  cure,  the  theory  of  primary  muscular  weakness  in  ana^mic-gastrop- 
totic  dyspepsia  is  evidently  incorrect;  and  the  cause  of  the  affection  is  to 
be  found  in  a  general  or  constitutional  disease. 

Consequently,  I  never  have  any  fear  of  resorting  to  forced  feeding 
in  cases  where  remnants  of  the  test-dinner  are  still  present  in  the  stomach 
seven  hours  after  eating,  if  the  patients  present  only  the  chnical  symptoms 
of  a  purely  functional  affection  of  the  stomach.  It  really  amounts  to 
malpractice  to  resort  to  gastropexy, — which  frequently  has  been  done, — for 
the  relief  of  this  condition,  since  this  procedure  exposes  the  patient  to  danger 
without  obtaining  more  relief  than  is  possible  by  forced  feeding  and   rest. 


184  DISEASES  OF  THE  DIGESTIVE  CANAL 

Diagnosis. — The  diagnosis  of  functional  ana^mic-gas- 
tropt(3tic  dyspepsia  is  made  from  the  above-mentioned  symp- 
tom,— namcl}',  pressure  in  the  stomach,  especially  after  meals, 
whether  fluids  or  sohds;  and  the  larger  the  meal,  the  greater 
the  disturbances. 

In  the  objective  examination,  the  physician  usually 
finds  normal  secretions  and  normal  motility  of  the  stomach. 

In  severe  cases,  there  is  sometimes  a  slight  delaj^  in  the 
expulsion  of  the  test-dinner  into  the  duodenum,  but  in  no 
ease  is  there  stagnation  of  food. 

The  total  acidity  may  be  slightl}"  increased  or  decreased, 
or  free  hydrochloric  acid  may  be  entirely  absent.  Usually, 
however,  there  is  a  variation  in  the  acidity;  for  instance,  one 
day  there  will  be  a  total  acidity  of  60  and  a  few  days  later  of 
30,  and  vice  versa.  In  this  disease,  there  are,  naturally, 
enteroptosis  and  impaired  nutrition. 

Differential  Diagnosis. — Ulcer  and  ectasia  are  easily 
differentiated  from  functional  dyspepsia,  since  in  both  of 
these  diseases  vomiting  is  a  symptom;  while  in  ulcer,  epi- 
gastralgia  is  prominent. 

Carcinoma  is  also  easy  to  exclude  from  the  diagnosis,  for 
the  reason  that  in  carcinoma  the  gastric  secretions  are  per- 
manently reduced,  and  the  course  of  the  latter  disease  would 
be  malignant. 

Only  in  chronic  gastritis  is  it  sometimes  impossible  to 
make  a  differential  diagnosis  from  antemic-gastroptotic  dys- 
pepsia without  the  use  of  the  stomach-tube,  since  in  this 
affection  pressure  in  the  stomach  also  occurs  after  meals. 

In  contradistinction  to  functional  dyspepsia,  however,  this 
pressure  does  not  occur  after  the  patient  has  taken  liquid  foods. 

In  addition  to  this  clinical  differentiation,  the  examiner 
may  prevent  confusion  in  his  diagnosis  by  giving  the  patient 
a  test-breakfast.  In  chronic  gastritis,  the  secretions  are 
persistently  increased,  diminished,  or  entirely  absent. 

The  anamnesis,  the  habitus,  and  the  ptosis  of  the  ab- 
dominal organs  in  enteroptotic  dyspepsia  give  further  clews 
for  a  differential  diagnosis. 


DISEASES  OF  THE  STOMACH  185 

Prognosis  and  Course. — The  clinical  course  of  the  disease 
is  eminently  chronic,  often  extending  over  decades,  for  the 
disease  may  exist  from  youth  to  old  age. 

It  generally  attacks  those  individuals  who  have  weak 
stomachs,  and  is  hereditary  in  the  same  sense  as  is  habitus 
enteropticus,  i.e.,  the  predisposition  is  inherited,  while  the  dis- 
ease itself  is  brought  on  by  unfavorable  influences  and  factors.* 

The  disease  shows  remissions, — healthy  periods  alter- 
nating with  illness, — according  to  whether  the  patient  is 
taking  the  proper  care  of  himself,  or  must  work  hard. 

It  is  worthy  of  mention  that  the  symptoms  of  ansemic- 
gastroptotic  dyspepsia  in  women  usually  disappear  during 
pregnancy, — which  is  very  simply  explained  from  the  fact 
that  the  abdominal  organs,  which  normally  have  a  low  posi- 
tion, are  then  supported  by  the  growing  uterus;  and  there 
is  also  the  favorable  influence  of  gravidity  upon  the  metabolic 
process  of  the  body.    This  fact  is  usually  observed  in  multiparse. 

The  disease  may  become  serious  through  complications; 
for  instance,  pulmonary  tuberculosis  may  develop  in  the 
patient  who  is  malnourished  and  weakened  by  the  disease. 

Habitual  constipation  is  a  very  frequently  resulting 
phenomenon  of  functional  dyspepsia,  because  the  patient, 
in  consequence  of  his  dyspeptic  disturbances,  eats  such  small 
amounts  of  food  that  there  is  not  sufficient  to  maintain  the 
normal  intestinal  peristalsis. 

Enteroptotic  dyspepsia  never  develops  into  gastrectasis 
without  the  occurrence  of  a  complication,  such  as  ulcer  of 
the  pylorus. 

Many  patients  of  insufficient  financial  means,  or  who 
lack  the  necessary  time  for  treatment,  are  never  cured. 

Treatment. — The  treatment  of  ansemic-gastroptotic  dj^s- 
pepsia  can  naturally  be  only  a  general  one,  to  strengthen  the 
weakened  constitution  and  to  increase  the  nervous,  muscular, 
and  circulatory  vigor  of  the  patient,  through  good  care, 
forced  feeding,  rest,  and  plenty  of  fresh  air. 

*  Of  atony,  one  might  say  with  Goethe,  "What  thou  hast  inherited  from 
thine  ancestors,  thou  must  win  in  order  to  possess." 


186  DISEASES  OF  THE  DIGESTIVE  CANAL 

In  many  cases,  a  change  of  scene  is  all  that  is  required 
to  add  tone  to  the  nervous  system  of  the  patient,  and  to 
increase  his  appetite,  therein'  improving  the  nutrition  and 
regulating  the  digestion. 

The  symptoms  of  the  disease  will  disappear  under  this 
regime,  without  the  institution  of  other  therapeutic  measures. 
Such  patients,  therefore,  do  not  require  the  treatment  given 
for  organic  affections  of  the  stomach  at  such  places  as  Carlsbad, 
Kissingen,  etc.,  and  should  in  general  avoid  the  use  of  the 
various  mineral  waters.  A  sojourn  at  some  health  resort, 
high  in  the  mountains  or  at  the  seaside,  is  more  suitable. 

Three  other  forms  of  hydrotherapeutic  procedures  are 
generally  useful,  which,  if  necessary,  may  be  carried  out  at 
home;  these  are  cold  friction  or  the  cold  pack,  the  half-bath, 
and  the  cold  douche. 

These  stimulating  treatments  should  not  be  used  if  the 
nervous  system  of  the  patient  is  in  an  irritable  condition,  as 
evidenced  by  exaggerated  knee-jerks,  excitement,  and  loss  of 
self-control  on  slight  provocation.  Protracted  lukewarm 
baths,  or  the  pine-needle  baths  are  preferable  in  such  a  case. 

As  a  household  treatment,  I  usually  begin  with  applications  of  cold 
moist  towels.  After  the  patient  has  become  accustomed  to  this  treatment, 
the  cold  wet  sheet-pack  should  be  applied  to  the  entire  body,  accompanied 
by  vigorous  friction,  given  by  an  expert  nurse,  if  possible. 

In  summer,  the  patient  should  take  cold  shower-baths  or  plunges  in 
a  lake  or  river.  A  weaker  patient  may  be  given  half-baths  instead,  sitting 
in  water  up  to  the  epigastrium,  at  a  temperature  of  25°  to  20°  R.  [88°  to 
78°  F.),  and  having  water  poured  over  him  at  a  temperature  of  20°  to  15°  R. 
[78°  to  68°  F.],  the  patient  meanwhile  rubbing  himself  vigorously  to  avoid 
becoming  cold.  The  entire  procedure  of  the  half-bath  should  not  exceed 
five  minutes,  and  the  best  time  for  its  use  is  early  in  the  forenoon. 

More  complicated  hydrotherapeutic  procedures  may  be  carried  out  in 
a  sanitarium  or  a  water-cure  establishment ;  although  in  most  cases  of  func- 
tional dyspepsia,  the  necessary  hydratic  procedures  may  be  given  at  home. 

Excessively  severe  treatment  is  harmful  and  should  be  avoided  in 
hysterical  and  irritable  patients,  and  naturally  in  cases  when  it  is  doubtful 
whether  an  organic  or  a  functional  dyspepsia  exists.  There  are  numeious  ex- 
amples of  cases  where  the  patient  was  made  worse  by  the  use  of  water,  applied 
\vith  the  assumption  that  a  nervous  affection  was  present,  when  in  reality  the 
trouble  was  due  to  an  ulcer  or  some  other  organic  disease  of  the  stomach. 


DISEASES  or  THE  STOMACH  187 

Diet. — In  every  case,  the  dietetic  treatment  is  the  most 
important  part  of  the  therapy.  It  effects  the  most  brilhant 
results,  but  these  can  be  fully  obtained  only  in  connection 
with  other  hygienic  factors,  such  as  fresh  air,  pure  water, 
and  the  avoidance  of  fatigue. 

The  diet  in  ansemic-gastroptotic  dyspepsia  must,  above 
all  things,  be  such  as  will  improve  the  nutrition  of  the  individ- 
ual. It  should  be  strengthening,  and  contain  considerably 
more  calories  per  clay  than  are  necessary  for  the  maintenance 
of  the  organism.  In  other  words,  the  patient  should  be  given 
the  rest-  and  fattening-treatment,  such  as  has  been  perfected 
by  Playfair  and  S.  Weir  Mitchell. 

Whenever  possible,  the  patient  should  absent  himself 
from  his  usual  occupation  for  about  six  weeks,  and  spend  the 
first  two  or  three  weeks  of  treatment  in  bed. 

It  is  preferable  that  such  cures  be  carried  out  in  a  sani- 
tarium. There  are,  however,  a  large  number  of  patients  who 
do  not  have  the  necessary  time  nor  sufficient  financial  means 
at  their  disposal  to  avail  themselves  of  the  advantages  of 
institutional  treatment,  so  that  it  is  often  necessary  to  at- 
tempt the  cure  by  ambulatory  treatment  at  home. 

The  diet-scheme  suitable  for  ambulatory  fattening-cure 
should  be  arranged  about  as  follows: 

The  articles  named  in  the  parentheses  are  suitable  if  the 
patient  is  at  the  same  time  suffering  from  chronic  constipation. 

7:00  a.m.      Tea  with  cream,  butter-rolls.     (Stewed  fruits,  mar- 
malade, honey,  whole-wheat  bread.) 
9:00  A.M.      Cereal  or  flour  soup  cooked  with  cream,  bread  and 
butter,  eggs  or  scraped  ham.     (Koumiss  or  butter- 
milk.) 
12:00    M.       Vegetables  cooked  with  butter,  boiled  or  roast  meats, 
sweet  fruit-sauces,  mild  pastries.     (Cider.) 
After  this  meal  the  patient  should  rest  in  a  recumbent  position  with 
loosened  clothes  for  one  or  two  hours. 

3:00  P.M.     Tea  with  cream,  etc.,  as  at  7:00  a.m. 
5:30  P.M.      Flour  soup,  etc. 

7:30  P.M.     Tea  with  cream,  bread  and  butter,  cold  meats  or  eggs. 
9:00  or  10:00  p.m.      Fruit. 


188  DISEASES  OF  THE  DIGESTIVE  CANAL 

As  might  be  expected,  patients  have  more  digestive 
disturbances  while  the  increased  amount  of  nourishment  is 
being  taken  during  the  first  two  or  three  weeks  of  the  fatten- 
ing-treatment,  than  the}'  had  when  on  the  previous  Htiuid 
diet.  The  physician  must  not,  however,  let  himself  be 
influenced  by  the  complaints  of  the  patient,  but  should 
energetically  insist  upon  his  adhering  strictly  to  \\\v  above- 
mentioned  diet-regime. 

The  physician  should  always  assure  himself,  by  means  of 
a  pair  of  scales,  whether  or  not  the  patient  is  increasing  in 
weight;  and  as  soon  as  there  is  a  gain  of  two  or  three  pounds 
in  weight,  the  patient  will  be  easily  convinced  that  his  stomach 
is  not  so  much  at  fault  as  he  had  supposed,  but  that,  on  the 
contrary,  his  digestion  is  quite  good;  and  as  he  gains  in  con- 
fidence, he  wall  be  much  more  walling  to  bear  the  possible 
discomforts  of  forced  feeding. 

Nausea  and  regurgitation,  which  frequently  occur  after 
meals,  should  not  be  given  too  much  attention. 

It  is  only  when  cramp-like  pain  and  diarrhoea  set  in, 
that  the  amount  of  food  should  be  lessened.  The  physician 
should  then  once  more  carefully  examine  the  patient  to  deter- 
mine whether  or  not  an  organic  affection  exists  which  had 
been  previously  overlooked. 

After  about  two  weeks'  treatment,  when  the  metabolism 
has  been  improved,  the  dyspeptic  disturbances  generally 
begin  to  disappear;  and  they  cease  entirely  after  about  three 
or  four  weeks  of  treatment. 

As  a  rule,  the  patient  will  have  gained  in  weight  a-bout 
eight  or  ten  pounds,  and  will  feel  strong  and  healthy  and  able 
to  enjoy  the  ordinary  household  diet  without  any  discomfort. 

With  sanitarium-treatment,  there  is  often  a  greater 
increase  in  weight,  and  a  still  more  rapid  and  striking  improve- 
ment in  the  condition  of  the  patient. 

An  actual  and  permanent  cure  is  obtained  by  this  plan 
of  treatment  if  the  dyspepsia  was  caused  solely  by  anaemia 
and  enteroptosis.  The  abdominal  organs,  especially  the 
capsules  of  the  kidneys  and  the  mesentery,  regain  their  normal 


DISEASES  OF  THE  STOMACH  180 

amounts  of  fat,  which  helps  to  cstabhsh  the  normal  equilib- 
rium and  position  of  these  organs,  while  the  general  treat- 
ment has  also  improved  the  quality  of  the  blood  and  led  to 
functional  energy  of  all  the  abdominal  organs. 

The  rest-fattening  cure,  however,  cannot  restore  all 
cases  of  dyspepsia  of  a  functional  nature. 

Those  patients  whose  nervous  systems  have  been  injured 
by  over-work,  dissipation  and  worry,  generally  have  only  the 
nutrition  restored  to  the  normal  by  the  fattening-cure,  their 
dyspeptic  symptoms  not  always  disappearing.  For  these 
cases,  mental  diversion  and  change  of  scene  are  absolutely 
necessary. 

Medicinal  Treatment. — The  drug-treatment  of  ana^mic- 
gastroptotic  dyspepsia  is  useful  only  in  so  far  as  it  assists  in 
carrying  out  the  diet-treatment,  by  stimulating  the  appetite 
and  suppressing  the  hypersesthesia  of  the  gastric  mucosa,  etc. 
These  indications  are  best  fulfilled  by  bitters  given  before  meals. 

The  following  prescriptions  are  examples: 

1.  I^     Tincturae  nucis  vomicse,  gtts.  xc-giiss  5.0-10.0 

Tincturse  gentianse  (or  tincturae  rhei),  ovss-viss     20.0-25.0 
M.  Sig. — Thirty   drops    10  to   15   minutes   before   meals  in  a 
wineglassful  of  water  or  on  sugar,  t.i.d. 

2.  I^     Tincturae  cinchonae,  3iss  50.0 

or  extracti  calami  fluidi,  ^iss  50.0 

or  tincturae  quassiae,  3  iss  50.0 

or  extracti  condurango  fluidi,  3  iss  50.0 
M.  Sig. — A  teaspoonful,  t.i.d. 

3.  I^     Acidi  hydroclilorici  diluti,    rt\xl  2.5 

(Tincturse  nucis  vomicae),  TTLxxxii       2.0 
Vini  condurango,  ^iiiss  100.0 

M.  Sig. — A  teaspoonful,  t.i.d. 

4.  I^     Extracti  cinchonae,   §1    30.0 
Sig. — Twenty  drops,  t.i.d. 

5.  I^     Tincturae  belladonnae  foliorum,  3  iss     5.0 

Extracti  condurango  fluidi,  ^viss      25.0 
M.  Sig. — Twenty-five   drops  t.i.d.,   for  hypersesthesia 
of  the  gastric  mucosa. 


190  DISEASES  OF  THE  DIGESTIVE  CANAL 

6.  I^     Extract!  nucis  vomicre, 

Extract!  belladonna*   foiionun,  fia  gr.  !vss     0.3 
'  Pulveris  glycyrrhizjE  composili,  gr.  xxiv        1.5 
M.  ft.  pil.  XXX.     S!g. — A  pill  after  eating,  t.i.d. 

7.  I^     Ferr!  reducti,  oiss  .  6.0 

Extract!  nucis  vomicte,  gr.  vi  0.4 

Quinina)  hydrochloridi,  5ss  2.0 

Acid!  arseno.si,  gr.  !  0.06 

Extract!  rhei,  gr.  xv  1.0 

Mass.  pill.  q.s.  ut  f.  pill.  No.  Ix.  Sig. — Two  pills  t.i.d.     (Biermer.) 

Massage  of  the  stomach,  and  also  of  the  intestine  when 
constipation  exists,  usually  affords  the  patient  considerable 
relief  during  the  rest-cure.  It  should  consist  chiefly  in  strok- 
ing the  epigastrium  with  the  flat  hand  after  meals  for  five 
or  ten  minutes.  This  produces  a  pleasant  and  agreeable 
feeling  of  warmth. 

In  organic  affections  of  the  stomach,  on  the  contrary, 
massage  usually  produces  unpleasant  results  and  often  pain. 

For  very  relaxed  patients,  the  physician  may  also  advise 
massage  of  the  entire  body,  in  order  to  stimulate  the  general 
metabolism,  while  the  local  massage  of  the  stomach  is  per- 
formed by  the  physician  personally  with  the  best  of  results. 

Remarks  on  Enteroptosis 

(Gastroptosis,  Nepliroptosis,  and    Pendulous  Abdomen) 

Glenard  was  the  first  to  appreciate  correctly  the  relation 
between  the  sinking  of  the  abdominal  organs  and  disorders 
of  the  digestive  tract.  He  showed  that  a  large  number  of  the 
nervous  affections  of  the  stomach  may  be  traced  to  this  ana- 
tomical condition. 

Stiller  recognized  that  the  fundamental  cause  of  enterop- 
tosis is  the  habitus  enteropticus.  Owing  to  the  fact  that  persons 
with  habitus  enteropticus  generally  possess  weak  constitutions, 
Stiller  has  designated  this  entire  type  of  individuals  as  having 
"asthenia  universalis  congenita." 

The  habitus  enterojjticus  is,  therefore,  congenital,  — 
while  enteroptosis,  or  Glenard's  Disease,  is  acquired 
through  various  factors  incident  to  modern  life. 


DISEASES  OF  THE  STOMACH  191 

It  is  possible  that  habitus  entcropticus  is  to  be  attributed  to  avatism, 
and  can  be  traced  to  the  time  when  human  beings  had  not  yet  assumed  the 
upright  posture;  for  in  no  animal  is  the  thorax  so  wide  as  in  man,  and  it  has 
probably  developed  only  gradually.  This  is  why  a  person  with  a  broad 
thorax  is  scarcely  ever  affected  with  enteroptosis,  since  his  organs  are  miich 
more  firmly  fixed  and  held  in  place. 

In  addition  to  congenital  or  constitutional  enteroptosis, 
there  is  an  acquired  or  local  form  which  occurs  in  women  after 
pregnancy  when  the  abdominal  walls  have  been  very  much 
distended. 

The  following  abdominal  organs  may  assume  an  abnor- 
mally low  position :  the  stomach  to  a  hand-breadth  below  the 
umbilicus;  the  transverse  colon  to  the  symphysis;  the  liver, 
and  more  rarely  the  spleen;  and  both  kidneys,  especially 
the  right  kidney. 

There  are  three  degrees  of  nephroptosis: 

The  first  degree,  when  the  lower  portion,  the  second 
degree  when  half  of  the  organ,  and  the  third  degree  when  the 
entire  kidney  is  palpable  during  deep  inspiration.  If  the 
kidney  remains  in  its  abnormal  position  during  expiration  and 
the  quiescent  respiratory  period,  the  condition  is  described  as 
dislocated,  floating,  or  movable  kidney  of  the  fourth  degree. 

Uncomplicated  floating  kidney  may  perhaps  cause  some 
discomfort  to  the  individual,  but  never  actual  pain. 

Treatment. — Therapy,  to  be  suitable  for  the  congen- 
ital or  constitutional  enteroptosis,  can  be  only  such  as  will 
tend  to  strengthen  the  weakened  constitution  of  the  patient; 
while  acquired  .enteroptosis,  produced  by  local  condi- 
tions, must,  in  addition  to  the  above,  be  treated  locally. 
In  this  form,  therefore,  the  application  of  suitable  abdominal 
bandages  is  indicated;  these  serve  to  restore  the  sunken 
abdominal  organs  to  their  normal  positions.  This  purpose  is 
fulfilled  by  most  of  the  abdominal  bandages  purchasable  in 
large  instrument-houses. 

To  prevent  the  upward  displacement  of  the  bandage, 
thigh-bands  should  be  used,  just  as  in  hernia  trusses  and 
bandages. 


192 


DISEASES  OF  THE  DIGESTR^E  CANAL 


Corsets  arc  absolutely  forbidden  in  enteroptosis.     Women 
with    entei'optosis    should    wear    "health-waists,"    to    which 


Fig.  31. 


Fig.  32. 


Fig.  33. 


Various  forms  of  abdominal  belts. 
Fig.  34. 


Stengel's  kidney  belt. 


the  skirts  are  buttoned,  or  the  skirts  may  be  supported  by 
straps  over  the  shoulders.     Street-clothes  should  also  be  worn 


DISEASES  OF  THE  STOMACH 


193 


supported  from  the  shoulders,  so  that  all  pressure  at  the 
waist  may  be  avoided. 

[The  above  statement  of  the  author,  in  which  he  says 
that  corsets  should  be  forbidden  in  enteroptosis,  evidently 
refers  to  the  older  form  of  corset  which  constricted  the  epi- 
gastrium and  crowded  downward  the  viscera  of  the  abdominal 
and  pelvic  cavities. 

The  more  recent  "corrective  straight  front"  corset,  if 
properly  made  and  fitted  by  a  corset-maker,  presses  inward 
and  upward  on  the  lower  abdomen,  serving  to  restore  to  their 


Fig.  35. 


Diagram  showing  the  adhesive  plaster  marked  for  cutting.* 
Fig.  3G. 


Diagram  showing  the  adhesive  plaster  belt. 

normal  position  organs  which  are  displaced  downward. 
Since  no  constriction  of  the  lower  thorax  and  of  the  epigastrium 
is  caused  the  wearer,  such  corsets  may  be  used  in  lieu  of  an 
abdominal  bandage  in  many  cases  of  enteroptosis.] 

In  women  with  normal  habitus,  however,  corsets  are  not 
forbidden;  it  is  even  better  to  wear  them  if  properly  fitted,  since 
without  corsets  the  skirts  are  simply  tied  around  the  waist, 
sometimes  causing  constricted  liver  and  other  disturbances. 

The  use  of  adhesive  plasters  as  a  substitute  for  abdominal  bandages  has 
been  recommended  by  two  American  authors,  Rose  and  Rosewater,  to  be 
applied  in  the  following  manner: 

*[The  sections  indicated  by  the  dotted  lines,  and  marked  (see  Fig.  35), 
are  separated  from  the  bandage  A,  and  laid  upon  it  in  reversed  position  so  as 
to  overlap  (see  Fig.  36) .] 

13 


194 


DISEASES  OF  THE  DIGESTIVE  CANAL 


The  ends  of  three  broad  strips  of  adhesive  plaster  are  applied  to  the 
lower  part  of  the  abdomen,  just  above  tlie  symphysis;  the  otlier  end  of  the 
middle  strip  is  then  brought  upward  and  applied  to  the  sternum.  The 
right  and  left  strips,  respectively,  are  drawn  obliquely  around  the  sides  of 
the  patient  and  adhere  to  the  spinal  column.  A  fourth  transverse  strip  of 
the  plaster  may  also  be  applied  across  the  abdomen  above  the  umbilicus. 

In  certain  cases,  this  adhesive  plaster  bandage  has  given  me  good 
results,  although  its  coatiiuied  use  is  generally  mipleasant  to  the  patient, 

Fin.  37. 


The  first  step  iu  the  application  of  tlie  adhesive  plaster  belt. 

causing  discomfort  during  the  night,  producing  eczema  and  sudamina,  and 
rendering  it  imj)ossible  for  him  to  bathe.  The  necessity  of  changing  the 
plaster  every  three  or  four  weeks  makes  it  rather  more  expensive  to  the 
patient  in  the  long  run  than  an  abdominal  bandage. 

[The  Rose  adhesive  plaster  bandage  may  also  be  applied  in  the  manner 
shown  in  Figs.  3.5,  36,  37,  38. 

A  strip  of  "  mole-skin "  plaster  seven  inches  in  width  and  of  sufficient 
length  is  cut  as  in  Figs.  35  and  36,  and  then  applied  as  in  Figs.  36  and  37. 

The  disagreeable  itching  and  skin  irritation  which 
sometimes  result  from  the  use  of  Rose's  adhesive  plaster  belt 
may  be  largely  avoided  if  certain  precautions  mentioned  by 


DISEASES  OF  THE  STOMACH 


195 


Rose  *  and  confirmed  by  experience  are  observed.  The 
so-called  "mole-skin"  plaster,  7  inches  wide,  is  preferable  to 
any  other.  Before  applying  the  plaster,  the  abdomen  should 
be  thoroughly  washed  with  alcohol  and  ether  to  remove  the 
fats  and  moisture  of  the  skin.  In  my  practice,  patients  have 
frequently  worn  one  belt  three  or  four  weeks  without  causing 
any  irritation  of  the  skin. 

Fig.  38. 


Tlie  second  step  in  the  application  of  the  adhesive  plaster  belt. 

I  usually  apply  the  adhesive  plaster  belt  preliminary  to 
prescribing  the  ordinary  abdominal  belt,  in  order  to  more 
accurately  estimate  the  amount  of  disturbance  caused  by 
the  enteroptosis,  and  to  more  intelligently  select  a  belt  which 
will  be  adaptable  for  prolonged  use.     (See  illustrations.)] 

Persons  who  have  enteroptosis  with  the  normal  habitus, 
especially  women,  have  quite  a  number  of  unpleasant  symp- 
toms, particularly  the  feeling  of  heaviness,  backache,  weight, 
and  even  of  a  complete  prolapsus  of  the  uterus,  also  drawing- 

*"Atonia  Gastrica,"  by  Rose  and  Kemp,  Funk  and  Wagnalls  Co.,  1905. 


196  DISEASES  OF  THE  DIGESTIVE  CANAL 

pains  in  the  sacrum  and  in  the  costal  arches,  especially  after 
hard   physical   labor  or  standing  for  a  long  time. 

It  need  not  be  especially  mentioned  that  both  ileus  and 
hernia  of  the  anterior  abdominal  wall  sometimes  occur  in 
severe  cases  of  enteroptosis. 

Either  congenital  or  acquired  enteroptosis  may  exist 
without  symptoms  as  long  as  the  nutrition  of  the  affected  individual  is  good. 

Sometimes  the  physician  accidentally  discovers  gastroptosis  or  a 
movable  kidney  when  examining  children  or  adults  with  good  digestion. 
According  to  Stiller,  such  a  finding  should  always  be  regarded  as  an  indica- 
tion that  such  individuals  are  predisposed  to  functional  disturbances  of  the 
stomach  and  intestine. 

Phthisical  Dyspepsia 

Although  dyspepsia  caused  by  phthisis  belongs  to  the 
large  group  of  ansemic-enteroptotic  dyspepsias,  the  subject 
will  be  given  separate  consideration  on  account  of  its  great 
practical  importance. 

Its  symptoms  are  exactly  the  same  as  those  of  anaemic- 
gastroptotic  d3'spepsia, — persistent  loss  of  appetite,  pressure 
and  fulness  after  meals — whether  solid  or  hquid  food, — 
regurgitation,  lassitude  and  weakness. 

Objective  symptoms  are  ptosis  and  easily  obtained  splash- 
ing sounds  in  the  epigastrium,  while  both  the  motility  and 
secretion  of  the  stomach  may  be  normal  or  only  slightly 
deviating  from  the  normal;  besides  severe  anaemia,  emacia- 
tion may  be  present,  as  well  as  the  symptoms  of  lung-affection. 

The  physician  should  make  it  his  absolute  duty  to 
examine  the  lungs  of  every  young  person  that  suffers  from  a 
persistent  dyspepsia,  and  he  will  doubtless  be  surprised  to  find 
how  frequently  tuberculosis  of  the  lungs  is  responsible  for 
what  has  been  treated  months  or  years  as  chronic  gastritis. 

Treatment. — The  therapy,  naturally,  should  deal  with 
the  primary  disease.  A  very  full,  rich  diet  should,  therefore, 
be  advised  in  spite  of  the  dyspeptic  complaints  of  the  patient. 
If  the  diet  is  such  as  to  improve  the  nutrition,  the  stomach- 
symptoms  will  disappear  of  themselves. 


DISEASES  OF  THE  STOMACH  197 

As  a  supporting  treatment,  creosote  combined  with  a 
bitter  may  be  prescribed,  and  is  best  given  in  the  form  of  the 
well-known  creosote-tincture,  which  contains  one  gram  of 
creosote  to  four  drams  of  tincture  of  gentian.  The  effect  of 
this  medicament  is  almost  specific  in  phthisical  dyspepsia. 
In  the  beginning,  I  prescribe  8  drops  three  times  daily  after 
eating,  in  a  teaspoonful  of  red  wine;  every  day  increasing 
the  dose  one  drop,  in  such  a  manner  that  on  the  fourth,  fifth 
and  sixth  days  the  patient  takes  9  drops  three  times  daily,  and 
on  the  seventh,  eighth  and  ninth  days  10  drops  three  times 
daily,  etc.,  until  20  drops  are  taken  three  times  daily,  which 
should  be  continued  for  about  three  months. 

In  well-marked  advanced  cases  of  phthisis  accompanied 
by  dyspepsia,  the  physician  will  obtain  very  good  results 
with  codeine. 

In  regard  to  the  relation  between  phthisis  and  dyspepsia, 
it  should  be  remarked  that  the  opposite  of  what  has  been  said 
above  is  sometimes  the  case,  when  dyspepsia  is  primary  and 
phthisis  secondary. 

CLINICAL    CASES 

Because  of  the  importance  and  frequency  of  functional  dyspepsia,  I 
have  added  quite  a  number  of  illustrative  cases. 

1.  Congenital  Cases 

Case  1. — Mr.  M.,  a  business  man,  33  years  old,  who  had  led  a  dissi- 
pated and  reckless  life.  For  two  years  he  had  suffered  from  a  feehng  of 
fulness  and  pressure  in  the  epigastrium,  and  from  eructations,  after  each 
meal.  The  appetite  was  good  and  the  bowels  regular.  He  had  never 
suffered  pain  in  the  epigastrium.  Patient  was  anaemic  and  thin,  weighed 
111  pounds  and  had  the  habitus  enteropticus.  The  test-breakfast  showed 
that  the  gastric  secretions  were  normal.  The  treatment  consisted  of 
forced  feeding  and  the  use  of  bitters.  In  six  weeks,  the  patient  had  gained 
.10  pounds  in  weight  and  later  was  completely  cured,  and  was  able  to  eat 
all  kinds  of  food  without  discomfort. 

Case  2. — Hedwig  Z.,  a  governess,  30  years  old,  for  four  years  had 
suffered  from  a  feeling  of  fulness  after  each  meal,  and  from  constipation, 
but  never  pain  or  vomiting.  The  appetite  was  poor.  The  patient  was 
ansemic,  emaciated,  and  had  ptosis  of  the  abdominal  organs.  The  test- 
meal  showed  normal  acidity  of  the  gastric  juice. 


198  DISEASES  OF  THE  DIGESTIVE  CANAL 

Tho  treatment  consisted  of  a  fattcninpi-oonstipation  diet,  and  bitters  and 
massage;  and  within  a  short  time  the  patient  was  free  from  all  discomfort. 

Case  3. — Gertrude  E.,  a  teacher,  23  years  old,  had  been  mentally 
over-worked  foi"  o\'er  a  year,  and  had  felt  exhausted  and  weak  for  five 
months  past,  with  no  appetite  and  with  constant  pressure  and  fulness  in 
the  epigastrium  after  eating  any  kind  of  food.  Occasionally  she  had  gone 
se^'eral  days  without  any  gastric  distiu'bances.  The  patient  was  ^'ery 
anaemic  and  emaciated.  She  had  the  habitiis  enteropiicus.  The  test-break- 
fast was  well  digested,  and  the  total  acidity  one  and  one-half  hours  after 
the  test-meal  was  78.  (Her  father  likewise  had  had  hyperacidity.)  The 
treatment  consisted  in  forced  feeding,  bitters,  and  rest  from  work.  She 
gained  four  pounds  in  weight  in  three  weeks  and  the  dyspeptic  complaints 
soon  ceased. 

2.  Cases  of  Acquired  or  Mixed  Forms  of  Ptosis 

Case  1. — Clara  M.,  30  years  old,  had  been  pregnant  twice.  Her 
father  had  died  three  months  previous  from  "large  spleen,"  since  which 
bereavement  the  patient  had  been  ill  from  loss  of  appetite,  rapid  satiation, 
and  the  feeling  of  pressure  and  fulness  in  the  epigastrium  after  eating  any 
kind  of  food.  The  bowels  had  been  regular  and  she  had  suffered  from  no 
pain  nor  vomiting.  Patient  was  very  anaemic  and  emaciated,  and  weighed 
114  pounds.  She  had  both  the  inherited  and  the  acquired  forms  of  ptosis. 
Her  right  kidney  was  movable  to  the  third  degree,  the  spleen  slightly 
enlarged,  the  colon  sunlcen,  and  loud  splashing  sounds  could  be  easily 
obtained  in  the  epigastrium.  The  treatment  consisted  of  ambulatory 
forced  feeding,  bitters  and  massage.  In  two  and  one-half  months,  patient 
had  gained  IS  pounds  in  weight,  was  fully  restored  to  health,  did  her  work 
without  fatigue,  and  was  able  to  eat  any  kind  of  food  without  discomfort. 

Case  2. — Mrs.  W.,  30  years  old,  had  been  pregnant  eleven  months 
previous.  For  six  months  she  had  suffered  from  pressure,  but  no  pain,  after 
eating.  The  patient  had  been  much  worried  for  the  past  six  weeks.  Stools 
were  regular.  Patient  was  very  anaemic  and  emaciated,  weighing  only  107 
pounds.  She  had  both  congenital  and  acquired  ptosis.  Both  kidneys  were 
movable  to  the  third  degree.  Loud  splashing  sounds  in  the  epigastrium 
were  easily  produced. 

Treatment. — Rest  in  bed,  forced  feeding,  and  bitters.  In  two  months 
she  was  free  from  all  discomfort  and  had  gained  5  pounds  in  weight;  after 
six  weeks,  her  weight  had  increased  to  117  pounds,  and  she  was  entirely  well. 

3.  Phthisical  Ffyspepsia 

Case  1. — Louise  W.,  31  years  old,  the  wife  of  a  merchant,  had  at  one 
time  been  pregnant.  Nepliroptosis  had  been  diagnosticated  ten  years  pre- 
vious. For  the  past  seven  or  eight  weeks,  she  had  had  poor  appetite,  sluggish 
stools,  pressure  and  fulness  after  eating,  which  were  relieved  by  assuming  a 


DISEASES  OF  THE  STOMACH  199 

recumbent  position.  She  had  night-sweats,  had  lost  20  pounds  in  weight, 
and  was  very  anaemic  and  emaciated.  She  had  the  habitus  enteropticus  and 
relaxed  abdominal  walls ;  both  kidneys  were  movable  to  the  second  or  third 
degree,  and  there  was  a  slight  catarrhal  involvement  of  the  right  apex.  No 
benefit  was  obtained  from  forced  feeding  and  the  use  of  bitters.  Patient 
was,  therefore,  sent  to  a  sanitarium  for  treatment. 

Case  2. — Heinrich  M.,  an  engineer,  23  years  old,  had  had  occasional 
stabbing  pains  in  the  epigastrium,  distention,  and  diarrhoea  for  two  years. 
For  six  or  eight  weeks  he  had  had  pressure  in  the  stomach  after  meals  and 
poor  appetite,  besides  quite  frequent  slight  chills,  expectoration  and  night- 
sweats.  He  had  been  treated  for  gastric  catarrh  with  a  light  liquid  diet.  He 
was  very  thin  and  anaemic,  and  had  the  habitus  enteropticus.  Rales  were 
heard  in  the  apices  of  both  lungs.  His  temperature  was  38.3  C.  The  test- 
breakfast  was  deficient  in  acids,  the  total  acidity  being  22.  Strong  splashing 
sounds  in  the  epigastrium  were  obtained.  The  patient  was  sent  to  Gorbers- 
dorf,  where  he  was  cured. 

Case  3. — Carl  P.,  a  farmer,  39  years  old,  had  for  six  months  had  pres- 
sure in  the  stomach  after  eating,  but  no  pain.  His  appetite  had  been  good. 
The  patient  had  habitus  enteropticus,  with  loosening  of  the  tenth  costal 
cartilages,  and  inflammatory  involvement  of  the  right  apex.  The  treat- 
ment consisted  of  the  administration  of  creosote  and  gentian.  The  pressure 
in  the  stomach  disappeared,  his  appetite  improved,  and  he  gained  four 
pounds  in  weight. 

Case  4. — Mrs.  T.,  28  years  old,  had  lost  her  mother  from  tuberculosis, 
and  one  sister  was  phthisical.  Two  years  previous,  the  patient  had  been 
treated  in  Wehrawald  for  tuberculosis  of  the  lungs.  Nine  months  ago  she 
gave  birth  to  a  child,  since  which  time  she  had  been  exhausted,  without 
appetite,  had  suffered  from  pressure  and  fulness  in  the  epigastrium  and 
regurgitation,  after  eating  any  kind  of  food.  Patient  was  very  much 
emaciated.  She  had  both  the  congenital  and  acquired  forms  of  ptosis,  and 
the  abdominal  walls  were  very  much  relaxed.  Both  kidneys  were  dislocated. 
There  was  catarrh  of  both  the  apices.  No  benefit  was  obtained  from  the 
forced  feeding,  bitters  and  massage.  Patient  was  sent  to  a  sanitarium, 
where  she  died  in  about  a  year. 

Nervous  Dyspepsia 

Nervous  dyspepsia  is  very  closely  associated  with  and 
related  to  ansemic-gastroptotic  dyspepsia.  There  are,  how- 
ever, a  few  points  so  essentially  different,  that  in  most  cases  a 
distinction  between  the  two  affections  is  possible. 

In  neither  form  of  dyspepsia  are  there  anatomical  lesions 
of  the  mucosa  of  the  stomach;  at  least,  we  are  unable  to  detect 
any  with  our  present  methods  of  examination. 


200  DISEASES  OF  THE  DIGESTIVE  CANAL 

While,  as  has  been  sufficiently  emphasized,  the  habitus 
enteropticiL§  together  with  emaciation  and  anirmia  arc  the 
predominating  signs  of  ana^mic-gastroptotic  dj^spepsia,  we  do 
not  always  find  these  present  in  a  purely  nervous  dyspepsia. 

The  latter  may  develop  in  persons  with  the  normal 
hahitus  if  the  nervous  system  becomes  unstable  and  irritable 
from  any  cause.  The  same  thing  occurs  in  persons  who  are 
well  nourished — only  more  rarely — if  they  arc  mentally  over- 
worked or  suffer  from  psychical  disturbances. 

Etiology. — Nervous  d3^spepsia  is  caused  by  disturbance 
of  the  vegetative  nervous  S3'stem, — the  sympathetic  nerve 
and  its  abdominal  branches,  the  splanchnic  nerves;  since 
the  sympathetic  nerve  stands  in  intimate  relationship  with 
all  the  organs  of  the  bod}',  the  affection  of  any  organ  may 
cause  nervous  dj'spepsia,  as  soon  as  the  sympathetic  nervous 
system  is  in  a  condition  of  unstable  equilibrium,  as, — for 
example,  in  hysteria. 

Nervous  dyspepsia  is,  therefore,  always  a  local  evidence 
of  a  general  nervous  condition.  A  pathological  alteration, — 
limited  to  the  nerves  supplying  the  stomach,  the  splanchnic 
nerve  or  Auerbach's  plexus, — is  not  probable,  as  the  symptoms 
of  a  general  neurasthenia  or  hysteria  are  alwa3^s  present  in 
such  cases. 

Mental  over-work,  especially  hurried  nervous  activity, 
emotional  depression  from  death,  sorrow,  and  care,  or  the 
fear  of  contagion  while  caring  for  cancer-  or  tuberculosis- 
patients,  or  fright,  or  trauma, — all  form  a  large  group  of 
etiological  factors. 

Another  large  group  of  causative  factors  is  associated 
with  disease  of  the  sexual  organs,  occurring  most  frequently 
in  men  with  phosphaturia,  prostatorrhoea,  spermaturia  and, 
in  short,  in  those  of  perverse  sexuality  and  those  who  indulge 
in  masturbation  and  in  coitus  interruptus;  while  in  women, 
the  chronic  diseases  of  the  pelvis,  which  need  not  be  men- 
tioned in  detail,  induce  a  like  result. 

Nervous  dyspepsia  is  also  frequently  found  in  persons 
who  suffer  from  chronic  constipation  or  diarrhoea. 


DISEASES  OF  THE  STOMACH  201 

Any  of  these  factors,  as  we  shall  sec  later  on  in  the  clinical 
cases,  may  be  associated  etiologically  with  nervous  dyspepsia. 

Symptomatology. — Actual  pain,  as  also  in  ana3mic- 
enteroptotic  dyspepsia,  never  occurs  in  nervous  dyspepsia, 
but  only  general  dyspeptic  disturbances,  such  as  pressure  and 
fulness  after  meals.  At  times,  these  symptoms  begin  after 
eating  only  light,  easily-digested  foods;  while  at  other  times 
there  is  no  discomfort,  even  after  heavy,  indigestible  foods. 

Additional  symptoms  are  distention  of  the  epigastrium, 
eructation,  and  regurgitation.  Actual  vomiting  does  not 
occur,  but  there  is  usually  an  irregular,  perverse,  or  complete 
loss  of  appetite. 

Very  frequently  there  is  a  persistent  pressure  in  the 
epigastrium  and  behind  the  sternum,  similar  to  the  sensation 
of  globus  hystericus. 

The  dyspeptic  symptoms  throughout  the  cHnical  course 
of  this  disease  are  dependent  upon  the  condition  of  the  ner- 
vous system.  With  physical  and  mental  rest,  the  symptoms 
disappear,  but  to  return  after  any  kind  of  excitement. 

The  objective  examination  in  nervous  dyspepsia  usually 
reveals  the  fact  that  the  stomach  is  normal  in  both  its  secre- 
tory and  motor  functions.  The  fasting  stomach  is  either  en- 
tirely empty  or  contains  only  a  few  cubic  centimetres  of  gastric 
juice;  and  no  remnants  of  the  Reigel  test-dinner  are  to  be  found 
in  the  stomach  seven  hours  after  eating.  An  hour  after  the 
Boas-Ewald  test-breakfast,  the  meal  is  found  well  digested; 
and  the  total  acidity,  as  a  rule,  amounts  to  from  40  to  70. 

It  is  peculiar  to  nervous  dyspepsia  that  there  occur  great  variations 
in  the  secretory  functions  of  the  stomach. 

In  the  same  patient,  the  examiner  may  find  a  total  acidity  of  60,  which 
a  few  days  later  may  be  40  and  at  another  time  20,  while  the  fourth  exami- 
nation may  again  show  60.  Free  hydrochloric  acid  may  be  entirely  absent, 
or  hyperchlorhydria  and  an  excessive  secretion  of  gastric  juice  may  occur. 
In  short,  the  condition  of  the  stomach  varies  with  that  of  the  nervous  system. 

On  the  other  hand,  gastric  ferments  are  always  present 
in  nervous  dyspepsia,  even  when  there  is  an  absence  of  free 
hydrochloric  acid. 


202  DISEASES  OF  THE  DIGESTIVE  CANAL 

For  further  details  in  regard  to  this  point,  the  reader  is 
referred  to.  the  chapter  on  Gastric  Ferments  in  the  General 
Section. 

Diagnosis. — From  the  facts  that  the  subjective  symptoms 
of  nervous  dyspepsia  are  so  manifold  and  variable,  and  that 
objective  symptoms  are  either  entirely  absent,  or  take  definite 
shape  only  after  prolonged  observation,  it  is,  in  many  cases, 
impossible  to  arrive  at  an  immediate  diagnosis;  and  the 
physician  should  withhold  his  opinion  until  repeated  exami- 
nations have  been  made. 

Of  first  importance  is  the  variation  of  the  stomach- 
secretions  and  the  dependence  of  the  dj'speptic  s3miptoms 
upon  the  conditions  of  the  nervous  system. 

Differential  Diagnosis. — The  differential  diagnosis  is  very 
easy  in  individual  cases  when  the  secretions  and  the  motor- 
power  of  the  stomach  are  normal.  In  other  cases  it  is  very 
difficult,  because  the  affection  may  be  easily  confused  with 
chronic   gastritis. 

Gastric  ulcer  may  be  excluded  from  the  diagnosis  with 
positiveness  by  the  occurrence  of  epigastralgia  at  an  almost 
regular  interval  after  eating;  while  in  nervous  dyspepsia, 
actual  pain  in  the  stomach  does  not  occur. 

One  of  the  sequelae  of  ulcer,— namely,  perigastritis, — 
more  frequently  leads  to  confusion  in  the  diagnosis  than  does 
ulcer.  The  details  of  the  symptomatology  of  this  affection 
are  given  in  the  chapter  on  Gastric  Ulcer.  It  need  only  be 
mentioned  here,  that  in  perigastritis  the  symptoms  and 
discomforts  of  the  patient  are  largely  dependent  upon  his 
physical  activity  and  are  but  slightly  influenced  by  the  condi- 
tion of  his  nervous  system. 

Gastric  hernia  sometimes  gives  rise  to  a  mistaken  diag- 
nosis, because  the  symptoms  of  this  condition  are  often  so 
atypical  and  vague  that  the  physician  may  classify  the  affec- 
tion as  ''nervous  dyspepsia." 

Occasionally,  cancer  of  the  stomach  is  not  recognized 
as  such,  and  is  considered  by  the  phj^sician  to  be  nervous 
dyspepsia. 


DISEASES  OF  THE  STOMACH  203 

Nervous  dyspepsia  is  differentiated  from  ana^mic-enterop- 
totic  dyspepsia, — first,  by  the  etiology;  and  second,  and 
more  significantly,  by  the  variabihty  of  its  symptoms. 

Anaemic-gastroptotic  dyspepsia  occurs  in  very  anaemic 
and  under-nourished  individuals  who  have  congenital  or 
acquired  enteroptosis.  The  symptoms  appear  acutely  after 
each  meal,  and  persist  unchanged  for  years  at  a  time,  dis- 
appearing only  when  the  patient  is  provided  with  improved 
hygienic  conditions. 

In  contrast  to  this,  the  clinical  symptoms  of  nervous 
dyspepsia  may  appear  also  in  well-nourished  individuals  with 
normal  habitus,  if  the  equilibrium  of  the  nervous  system 
has  been  disturbed. 

If  hyperacidity,  subacidity,  or  anacidity  is  present  in 
a  case  of  nervous  dyspepsia,  confusion  with  hyperacid  gas- 
tritis or  anacid  gastritis  is  possible,  especially  if  only  a  single 
chemical  examination  of  the  stomach  has  been  made. 

If  the  examiner  can  demonstrate  sudden  variations  in 
■the  secretory  functions  of  the  stomach,  gastritis  is  naturally 
excluded.  Unfortunately,  from  the  standpoint  of  diagnosis, 
there  are  cases  of  nervous  dyspepsia  associated  with  constant 
hyperchlorhydria  or  subacidity  of  the  gastric  juice,  when 
confusion  as  to  the  nature  of  the  condition  can  be  prevented 
only  by  the  ensemble  of  all  symptoms  of  the  disease,  and  by 
accurate  determination  of  the  etiology. 

For  instance,  in  acid  gastritis  there  is  usually  a  history 
of  excesses  in  drinking,  smoking,  and  eating;  and  in  subacid 
or  anacicl  gastritis,  a  history  of  prolonged  alcoholism,  hasty 
eating,  imperfect  mastication  and  the  misuse  of  laxatives. 

The  rennin  and  pepsin  ferments  are  almost  always  present 
in  normal  amounts  in  nervous  dyspepsia.  This  finding  alone, 
however,  is  not  a  positive  differential  point,  because  these 
may  also  be  present  in  approximately  normal  amounts  in 
mild  cases  of  gastritis. 

The  determination  as  to  whether  any  given  case  is  one 
of  nervous  dyspepsia  or  not,  is  of  utmost  importance  in  the 
indications  for  treatment. 


204  DISEASES  OF  THE  DIGESTIVE  CANAL 

In  doubtful  cases,  it  is  always  better  for  the  physician 
to  prescribe  a  treatment  which  is  suitable  for  an  organic 
affection,  since  this,  under  no  condition,  can  injure  the  patient; 
for  instance,  if  the  typical  ulcer-cure  has  been  given  without 
obtaining  positive  results,  the  clinician  may  then  regard  the 
case  as  one  of  nervous  dyspepsia  and  may  proceed  with  a 
treatment  directed  toward  restoring  the  nervous  S3^stem  to 
its  normal  condition. 

Prognosis  and  Course.— Nervous  dyspepsia  scarcely  ever 
progresses  into  an  organic  disease  of  the  stomach,  and  then 
only  in  consequence  of  loss  of  appetite  and  malnutrition  of 
the  patient,  which  latter  leads  in  turn  to  severe  anaemia  and 
emaciation  (a  loss  in  weight  amounting  to  as  much  as  50 
pounds  has  been  observed),  tuberculosis,  and  very  frequently 
to  chronic  constipation,  with  its  sequela?, — hypochondriasis, 
secondary  intestinal  catarrh,  membranous  colitis,  etc. 

On  the  contrary,  gastrectasia,  gastritis,  ulceration,  cancer, 
and  hypersecretion  never  develop  from  nervous  dyspepsia. 

The  clinical  course  is  often  tedious, — improvement  alternat- 
ing with  relapses, — depending  upon  the  condition  of  the  general 
nervous  system.  If  the  disturbing  factors  cannot  be  eliminated 
from  the  lives  of  these  patients,  cure  is  often  impossible. 

On  the  other  hand,  a  sHght  psychical  improvement  in 
the  patient,  especially  in  women,  often  enables  the  physician 
to  obtain  within  a  few  days  surprisingly  favorable  results. 

Treatment. — Contrary  to  the  treatment  of  organic  dis- 
eases of  the  stomach,  the  therapy  of  nervous  dyspepsia  should 
not  be  directed  to  the  removal  of  local  complaints,  but  to  the 
improvement  of  the  general  condition  of  the  patient,  which 
involves  the  restoration  of  the  nutrition  and  the  toning  up 
of  the  entire  nervous  system. 

The  dyspeptic  symptoms  often  disappear  simply  through 
prolonged  rest  in  bed,  better  nourishment,  and  the  removal 
of  those  factors  which  weaken  and  irritate  the  nervous  system, 
— such  as  noises  in  the  streets,  etc. 

A.  Dietetic  Treatment. — The  dietary  should  always  be 
adaptable  to  the  physical  constitution  of  the  patient.     Forced 


DISEASES  OF  THE  STOMACH  205 

feeding,  which  was  described  in  the  previous  chapter,  is  suit- 
able only  for  those  cases  of  nervous  dyspepsia  in  which  mal- 
nutrition is  an  associated  condition. 

A  patient  with  normal  nutrition, — for  instance,  one  with 
thick  panniculus  adiposus, — naturally  does  not  require  forced 
feeding,  and  only  rarely  should  a  rest-cure  be  instituted. 

Obese  persons  with  nervous  dyspepsia  should  be  given  a 
diet  which  will  bring  about  a  decrease  in  weight, — starches 
and  fats  being  avoided  as  much  as  possible. 

For  constipated  patients,  a  rational  constipation-diet, 
such  as  is  described  in  the  chapter  on  Chronic  Constipation, 
should  be  prescribed,  for  the  reason  that  very  frequently 
constipation  aggravates  the  symptoms  of  nervous  dyspepsia 
or  may  even  be  the  cause  of  the  affection.  In  individual 
cases,  mild  laxatives  may  be  used  if  spontaneous  evacuation 
of  the  bowels  does  not  result  from  the  diet  alone;  the  most 
suitable  in  such  instances  being  regulin,  tamarinds,  purgen, 
etc.     (See  below.) 

In  order  to  convince  the  patient  that  it  is  not  his  stomach  that  is  dis- 
eased but  his  nervous  system,  the  physician  should  insist,  at  the  very  begin- 
ning of  treatment,  that  he  give  up  the  bland,  non-irritating  diet-regime 
which  he  has  been  wrongly  following,  either  of  his  own  accord  or  upon  the 
advice  of  the  attending  physician,  under  the  misconception  that  his  trouble 
was  chronic  catarrh  of  the  stomach.  As  soon  as  the  patient  is  shown  that 
a  full  diet  produces  no  greater  discomfort  than  a  mild  diet,  he  gains  con- 
fidence and  more  readily  follows  the  advice  of  the  physician. 

Since  in  severe  cases  of  nervous  dyspepsia,  the  rest-cure 
and  forced  feeding  may  not  be  sufficient  to  bring  about 
recovery,  it  may  be  preferable  for  the  patient  to  be  treated  in 
a  sanitarium  which  is  well  equipped  with  the  necessary  hydro- 
therapeutic  apparatus,  and  which  has  beautiful  surround- 
ings and  is  distant  from  a  large  city. 

In  the  dietetic  treatment,  it  must  again  be  strongly 
emphasized  that  in  doubtful  cases,  that  is,  if  the  physician  is 
not  sure  as  to  whether  an  organic  or  a  nervous  affection  of  the 
stomach  be  present,  he  should  at  first  prescribe  a  diet  which 
is  suitable  for  the  organic  disease;    also  in  cases  where  a  neu- 


206  DISEASES  OF  THE  DIGESTIVE  CANAL 

rosis  is  combined  with  an  organic  disease  of  the  stomach, — 
as  for  instance,  nervous  dyspepsia  with  acid  gastritis. 

B.  Hygienic  Treatment. — This  Hne  of  therapy  includes 
all  those  adjuncts  necessary  for  the  treatment  of  nervous 
affections  in  sanitariums  and  watering  places, — namely, 
rest-cure,  diversion,  baths,  gymnastics,  massage  and  electricity. 

We  cannot  enter  into  the  details  of  these  measures,  since 
they  do  not  concern  the  practicing  physician  so  much  as 
those   conducting  such  institutions. 

It  is  often  very  difficult  for  the  physician  to  decide  upon 
the  most  suitable  sanitarium  or  bathing  resort.  The  follow- 
ing general  rules  may  serve  to  guide  him: 

Patients  with  relaxed  and  depressed  nervous  systems  who  are  in  a 
fair  condition  of  nutrition  should  be  sent  to  the  seaside,  unless  there  is  present 
a  marked  degree  of  auEemia.  The  Baltic  Sea  is,  as  a  rule,  more  suitable  for 
women  and  the  North  Sea  for  men. 

Nervous  dyspeptics  with  an  irritable  condition  of  the  nervous  system 
should  be  sent  to  the  mountains;  those  who  are  well  nourished  to  the  higher 
ranges,  such  as  the  Tyrol  or  the  Bavarian  Alps;  while  ansemic  patients 
should  be  sent  to  mountains  of  medium  altitude,  such  as  the  Black  Forest, 
the  Hartz,  Thuringen,  and  the  Riesengebirge. 

The  deciding  factors,  therefore,  in  the  choice  of  the  sanitarium  or 
resort  are  the  state  of  the  general  nutrition, — obesity,  angemia,  etc., — and 
the  condition  of  the  nervous  system,  which  is  best  indicated  by  the  reflexes. 

Ansemic  and  very  nervous  patients  should  not  be  treated 
with  cold-water  procedures,  but  with  protracted,  lukewarm, 
full  baths,— such  as  are  given,  for  example,  in  Landeck, 
Elster,  Badenweiler,  etc.  The  same  principles  should  govern 
their  home  treatment. 

Massage  also  should  be  used,  with  caution.  As  a  rule, 
fight  massage  with  friction  of  the  epigastrium  and  the  abdomen 
are  indicated.  AH  of  the  more  severe  procedures,  such  as 
heavy  massage,  clapotement,  etc.,  only  aggravate  the  dys- 
peptic symptoms;  while  the  mild  stroking  movements  give 
considerable  aUeviation.  This  mild  massage  with  friction  is 
what  the  ''quacks"  designate  as  "magnetism." 

C.  Suggestive  Treatment. — This  consists  of  verbal  sugges- 
tions  and   the  influence  of  the  personafity  of  the  physician 


DISEASES  OF  THE  STOMACH  207 

upon  his  patient,  and  in  the  personal  trust  which  the  patient 
has  in  the  physician's  assurance  that  no  severe  stomach- 
affection  exists  and  that  only  an  atonic  condition  of  the 
nerves  supplying  the  stomach  is  causing  the  trouble.  The 
mere  frequent  repetition  of  these  facts  is  often  productive  of 
actual  improvement  and  even  cure  of  the  nervous  dyspepsia. 

More  susceptible  and  ignorant  patients  should  be  treated 
with  electricity  and  effleurage  of  the  epigastrium,  for  they 
often  believe  that  the  "magnetic"  treatment  which  they  are 
receiving  has  great  curative  powers.  In  practice  this  method 
works  wonders  with  such  patients. 

Treatment  by  electricity  also  belongs  to  the  realm  of 
suggestive  therapeutics.  It  may  be  dispensed  with  as  a  rule, 
and  is  generally  more  suitable  for  sanitarium-treatment; 
although  in  chronic  cases  very  good,  though  transient,  results 
are  often  obtained  by  its  use.  It  is  beneficial  only  to  those 
who  believe  in  its  heahng  power  and  who  have  the  utmost 
confidence  in  the  physician. 

It  need  scarcely  be  mentioned  that  in  irritable  cases  of  nervous  dys- 
pepsia the  galvanic  current,  and  in  relaxed  patients  the  faradic  current, 
should  be  used.  The  electricity  should  be  applied  externally  by  means  of 
two  moistened  electrodes, — one  placed  on  the  back  and  the  other  on  the 
epigastrium.  If  the  physician  prefers,  endofaradization  may  be  given.  A 
flat  electrode  is  placed  upon  the  epigastrium;  and  after  the  patient  has 
drunk  a  glass  of  water,  a  stomach-electrode  (which  may  be  obtained  in  any 
large  instrument-house)  is  introduced  into  the  stomach. 

Instead  of  the  regular  stomach-electrode,  an  ordinary  stomach-tube  may 
be  used.  No.  8  or  9  [Am.  No.  20-21],  closed  at  the  upper  end  by  a  small  cork 
through  which  a  copper  wire  has  been  pushed.  The  copper  wire  should  extend 
to  the  blind  end  of  the  stomach-tube,  and  the  proximal  end  should  then  be 
connected  with  the  electrical  apparatus.  The  current  should  be  weak  at  first 
and  gradually  increased  in  strength  as  long  as  it  can  be  borne  by  the  patient. 
The  duration  of  an  endofaradization  treatment  should,  as  a  rule,  be  about  5 
minutes,  while  the  external  electrical  treatment  should  last  10  to  15  minutes. 

D.  Medicinal  Treatment. — Sedatives, — such  as  bromides, 
— are  the  most  general  medicinal  agents  to  be  used  in  the 
treatment  of  nervous  dyspepsia.  The  physician  may  pre- 
scribe either  a  glass  of  effervescent  bromide-salts  night  and 
morning,  or  one  of  the  following  prescriptions: 


208  DISEASES  OF  THE  DIGESTIVE  CANAL 

1.  T^     Validol,  3iv     15.0 
Sig. — Six  to  ten  drops  t.i.d. 

2.  I^     Sodii  bromidi,  5i     30.0 

Sig. — A  knifepoint  twice  a  day,  or  fifteen 
grains  in  a  cup  of  valerian  tea. 

3.  J\     SjTupi  hypophosphitum,  5ii     60.0 
Sig. — A  teaspoonfiil  t.i.d. 

4.  1^     Extracti  cannabis  indicse,  gr.  I     0.05 

Sacchari,  gr.  viiss  0.5 

M.  ft.  pulv.  No.  X.     Sig. — One  powder  twice  daily 
(or  8  to  10  drops  of  the  tincture). 

5.  I^     Chloral  hydratis,  oi  4.0 

Syrupi  aurantii  corticis, 
Aquae,  aa,  oi  30.0 

M.  Sig. — A  teaspoonful  t.i.d. 

Bromides  are  suitable  for  nervous  dyspepsia  of  the  excit- 
able type  only.  In  the  depressed  form  of  the  disease,  with  a 
diminution  of  the  appetite,  general  despondency  and  hypo- 
chondria, bitters  should  be  given,  just  as  in  ana^mic-enterop- 
totic  dyspepsia;  and  they  are  equally  successful  in  causing 
the  disappearance  of  many  of  the  annoying  symptoms. 

The  following  are  the  clinical  histories  of  a  few  cases  of 
nervous  dyspepsia,  which  serve  to  illustrate  the  character- 
istics of  this  disease  better  than  prolonged  detailed  description. 

CLINICAL    CASES 

Case  1. — Mrs.  Ida  A.,  27  years  old,  had  always  been  very  nervous  and 
subject  to  hysterical  crying.  She  had  inherited  a  neurotic  tendency  from 
her  father,  and  had  frequently  been  subject  to  tremors,  headaches,  nausea, 
and  vomiting.  She  had  been  married  for  three  years  but  had  had  no  children. 
Menstruation  had  always  been  irregular,  often  not  occurring  for  months. 
According  to  the  statement  of  the  patient,  both  ovaries  had  been  prolapsed. 
She  complained  of  loss  of  appetite  and  a  feehng  of  great  pressure  in  the 
epigastrium,  which  was  often  entirely  independent  of  both  the  quality  and 
quantity  of  food  eaten,  as  sometimes  she  could  eat  any  kind  of  food,  and  at 
other  times  she  suffered  from  dyspepsia  even  after  liquids.  The  bowels  were 
sluggish.  Stools  were  formed,  of  large  caliber  and  hard.  The  use  of  lax- 
atives was  often  necessary. 


DISEASES  OF  THE  STOMACH  209 

Examination  showed  that  she  was  well  nourished,  with  an  alternating 
paling  and  flushing  of  the  skin.  The  patient  had  a  typical  habitus  enter- 
opticus,  the  right  kidney  was  movable,  and  the  patellar  reflexes  were  remark- 
ably exaggerated. 

The  treatment  consisted  of  a  fattening-constipation  diet,  warm  baths, 
and  a  large  knifepoint  of  bromide  of  potassium  three  times  daily,  together 
with  a  glass  of  valerian  tea.  After  one  week  of  treatment,  the  patient  had 
normal  evacuations  of  the  bowels,  the  pressure  in  the  stomach  had  dimin- 
ished, and  three  weeks  later  had  entirely  disappeared.  The  patient  had 
gained  four  pounds  in  weight  and  was  in  good  health.  In  this  case,  much 
benefit  was  obtained  from  suggestive  therapy. 

Case  2. — Oswald  K.,  a  teamster,  26  years  old,  had  masturbated  for 
years.  For  several  months  previous  he  had  had  constant  pressure  in  the 
stomach,  more  intense  after  heavy  meals.  He  had  never  had  epigastric  pain 
or  vomiting.  Stools  were  fairly  regular.  Patient  was  emaciated  and  pale. 
He  had  habitus  enteropticus.  The  test-breakfast  showed  the  gastric  juice  to 
be  subacid,  the  total  acidity  amounting  to  36. 

Treatment. — Bitters,  fattening-constipation  diet,  and  cold  frictions. 
Within  three  or  four  weeks  the  patient  was  absolutely  free  from  all  of  his 
former  trouble  and  remained  entirely  well  during  the  whole  two  years  that 
he  was  under  observation. 

Case  3.— Harry  T.,  a  business  man,  27  years  old,  had  for  two  years 
had  dyspepsia,  with  fulness  and  pressure  in  the  epigastrium  after  meals, 
loss  of  appetite,  eructations,  and  constipation.  Since  this  period  he  had 
lost  35  pounds  in  weight.  The  patient  had  for  years  over-worked  in 
attending  to  his  business.  He  was  very  anaemic,  and  habitus  enteropticus 
was  marked.  The  test-breakfast  was  well  digested,  with  a  total  acidity  of 
74.  After  six  weeks  of  treatment  in  the  sanitarium  at  Thalheim,  the  patient 
returned  completely  cured  of  his  dyspeptic  troubles,  and  having  gained  20 
pounds  in  weight. 

Special  Forms  of  Neuroses  of  the  Stomach 

In  the  modern  text-books  on  gastric  diseases,  by  Ewald, 
Boas,  Rosenheim,  Riegel,  etc.,  the  gastric  neuroses  are  sche- 
matically classified  into  secretory,  sensory  and  motor  neuroses, 
according  to  the  individual  functions  of  the  stomach. 

In  a  book  such  as  this,  however,  which  is  intended  as  a 
practical  guide  in  the  diagnosis  and  treatment  of  digestive 
diseases,  it  would  be  impracticable  to  conform  to  this  classi- 
fication. Such  a  work  can  discuss  in  detail  only  the  more 
common  forms,  not  mentioning  those  which  are  rarely  en- 
countered,  and  whose  treatment   had  better  be  left  to  the 

14 


210  DISEASES  OF  THE  DIGESTIVE  CANAL 

attention  of  a  specialist.  With  tliese  preliminaiy  explanatory 
remarks,  the  following  text  will  be  better  understood  and 
appreciated  by  the  reader. 

1 .    Nervous  or  Reflex  Vomiting 

(Including  Nervous  Eructation  and  Regurgitation) 

By  the  term  ''nervous  vomiting"  we  define  that  form  of 
gastric  neurosis  which  is  accompanied  by  vomiting  of  all 
food  eaten, — this  being  due  to  a  purely  nervous  irritation, 
especially  of  the  gastric  nerves,  without  there  being  any 
demonstrable  pathological  changes  of  the  stomach. 

Nervous  vomiting  occurs  most  commonly  in  women, 
especially  at  the  beginning  of  menstruation  and  in  the  meno- 
pause.    Men  are  very  rarely  affected. 

Nervous  vomiting  always  occurs  in  a  neuropathic  in- 
dividual, and  is  due  to  some  such  exciting  cause  as  over- 
work, agitation,  anger,  sorrow,  masturbation,  trauma,  etc. 

The  patient  vomits  all  foods, — liquids  as  well  as  solids, — 
almost  immediately  after  eating.  The  determination  of  this 
fact  in  the  anamnesis  is  of  exceptional  importance,  because 
vomiting  occurring  within  the  first  ten  or  fifteen  minutes 
after  eating  is  not  met  with  in  any  other  disease,  if  we  exclude 
stenosis  of  the  oesophagus  and  cerebral  affections. 

Nervous  vomiting  is  not  associated  with  pain.  The  sub- 
jective symptoms  consist  rather  of  pressure  in  the  stomach, 
feeling  of  fulness,  loss  of  appetite,  and  sometimes  repugnance 
toward  food,  just  as  in  other  forms  of  functional  dyspepsia. 

It  is  a  striking  symptom  of  nervous  vomiting  that  patients, 
in  spite  of  their  frequent  vomiting,  are  usually  but  slightly 
emaciated,  although  they  very  often  become  anaemic. 

Differential  Diagnosis. — A  large  number  of  affections 
come  into  question  in  the  differential  diagnosis  of  nervous- 
hysterical  vomiting. 

First  of  all,  the  vomiting  of  pregnancy  must  be  excluded, 
which  is  sometimes  a  difficult  task;  likewise  other  abnormal- 
ities of  the  generative  organs, — especially  displacement  of 
the  uterus, — which  very  frequently  cause  reflex  vomiting. 


DISEASES  OF  THE  STOMACH  211 

The  periodical  vomiting  associated  with  the  gastric 
crises  of  locomotor  ataxia,  which  will  be  spoken  of  in  another 
chapter,  should  also  be  eliminated  from  the  diagnosis,  and 
likewise  all  other  affections  with  which  vomiting  might  be 
associated.  I  will  mention  only  migraine,  cerebral  affections, 
acute  peritonitis,  chronic  nephritis,  nephrolithiasis,  and  above 
all,  helminthiasis  in  children. 

Vomiting  in  children,  the  so-called  '' juvenile  vomiting," 
is  quite  frequently  observed  in  nervous  and  antemic  children, 
and  represents  a  special  form  of  gastric  neurosis.  It  appears 
from  the  eleventh  to  the  thirteenth  years  in  children  who  have 
previously  been  healthy,  about  the  time  they  enter  school. 

In  some  of  these  cases,  early  masturbation  is  the  cause; 
while  in  others,  worms  are  the  exciting  factor.  In  these  cases 
the  stools  should  be  carefully  examined  for  ova  of  intestinal 
parasites,  the  details  of  which  will  be  given  in  the  chapter  on 
Microscopical  Examination  of  the  Faeces.  It  is  well  known 
that  the  vomiting  may  also  occur  from  the  intestinal  irrita- 
tion resulting  from  ascarides,  oxyuria,  and  other  small  worms, 
as  well  as  from  the  presence  of  tapeworms. 

Both  chronic  and  subacute  gastro-enteritis  in  children 
is  also  frequently  the  cause  of  vomiting.  In  these  conditions, 
it  is  characteristic  that  the  vomiting  is  always  dependent  upon 
the  quality  of  food,  and  occurs  after  eating  such  heavy  foods 
as  potatoes,  bread,  acids,  or  fruits,  etc.,  but  not  after  liquids. 

An  incomplete  or  rudimentary  vomiting, — the  well- 
known  regurgitation  of  food  a  short  time  after  eat- 
ing,— should  be  discussed  here.  It  occupies  a  middle  position 
between  simple  eructation  and  vomiting  and  is,  as  a  rule, 
associated  with  eructations  of  chyme,  the  mouth  becoming 
full  of  stomach-contents  which  have  a  bitter,  acid  taste, 
due  to  the  presence  of  gastric  acids  and  peptone.  After  regur- 
gitation the  food  is  expelled  from  the  mouth. 

This  condition  should  be  chnically  differentiated  from 
an  associated  one  known  as  rumination,  which  is 
most  frequently  observed  in  men  who  have  indulged  in  irreg- 
ular and  hasty  eating  for  years. 


212  DISEASES  OF  THE  DIGESTIVE  CANAL 

These  patients  regurgitate  food  soon  after  tlie  meal,  and, 
instead  ofspitting  it  out,  chew  it  and  swallow  it  again. 

Nervous  eructation  occurring  in  diseases  of  the 
oesophagus,  as  has  already  been  mentioned,  is  sometimes 
observed  with  nervous  vomiting.  These  affections  are  often 
seen  one  after  the  other  in  the  same  individual. 

Heartburn,  or  pyrosis  h  y  d  r  o  c  h  1  o  r  i  c  a  ,  is 
associated  with  nervous  vomiting,  although  it  is  also  a  symp- 
tom of  such  organic  affections  of  the  stomach  as  gastric 
ulcer  and  acid  gastritis.  For  details,  see  the  chapter  on 
Hyperchlorhydria. 

Prognosis. — The  prognosis  of  nervous  vomiting  is, — as 
a  rule, — good,  although  its  chnical  course  covers  a  long 
period  of  time. 

The  affection  disappears  spontaneously  after  the  nervous 
system  has  been  restored  to  its  normal  tone. 

Treatment. — The  therapy  should  be  directed  chiefly  to 
the  removal  of  those  factors  in  the  life  of  the  neuropathically 
inclined  individual  which  have  given  rise  to  the  neurosis. 

Usually  we  have  to  do  with  the  removal  of  various  mental 
conditions;  although  it  is  self-evident  that  such  factors  as 
diseases  of  the  genital  organs,  particularly  in  women,  should 
be  excluded  to  prevent  confusion  of  nervous  vomiting  with 
the  reflex  vomiting  of  pregnancy,  etc. 

The  therapy  should,  therefore,  be  largely  of  a  suggestive 
nature,  and  should  include  bromide  and  valerian  preparations, 
just  as  in  nervous  dyspepsia. 

I  generally  give  the  test-breakfast  in  such  cases,  following  m}^  rule  of 
systematically  examining  every  patient.  The  advantage  of  doing  this  with 
such  patients  is,  that  the}^  feel  that  the  physician  is  interested  in  their  indi- 
vidual affection  and  they  are  afterwards  more  easily  assured  that  the  stomach 
is  performing  its  normal  functions  and  that  only  the  nerves  are  affected. 
This  assurance  and  conviction  tend  considerably  toward  the  quieting  of  the 
nervous  sj^stem,  which  indirectly  brings  about  a  cure. 

On  the  same  basis  of  suggestion,  I  sometimes  lavage  the 
mucous  membrane  of  the  stomach  of  such  a  patient  with  luke- 
warm  water,   using   Rosenheim's   irrigation-tube,   and   some- 


DISEASES  OF  THE  STOMACH  213 

times  also  resort  to  endofaradization,  as  has  been  mentioned 
in  the  previous  chapter. 

I  have  had  much  better  resuhs  from  effleurage  of  the  epigastrium, 
which  should  be  carried  out  as  follows: 

The  physician  should  lightly  stroke  the  region  over  the  stomach  with 
both  hands,  the  right  alternating  with  the  left,  using  a  gentle  and  slightly 
vibratory  movement;  and  it  so  happens  that  ignorant  and  susceptible 
patients  often  think  they  are  being  "magnetized."  By  this  procedure  I 
have  often  seen  the  most  striking  results  after  three  or  four  treatments,  so 
that  patients  who  had  a  short  time  previously  vomited  everything  they 
had  eaten  were  able  to  digest  the  heaviest  foods  without  any  trouble. 

The  appended  histories  of  clinical  cases  best  represent  the 
clinical  course  and  treatment  of  nervous  vomiting.  Naturally, 
the  treatment  must  always  be  selected  and  adapted  for  each 
individual  case.  For  instance,  the  ''magnetizing"  treatment 
would  be  quite  unsuitable  for  the  intellectual  class  of  patients. 

There  are  numerous  cases  of  nervous  vomiting  in  which 
the  nervous  system  has  been  so  disturbed  through  over- 
work for  a  number  of  years  that  all  therapeutic  measures  are 
without  effect.  In  these  cases  only  prolonged  residence  in 
other  climates,  as  in  the  Riviera,  or  the  high  altitudes,  or 
a  lengthy  stay  at  a  suitable  sanitarium,  will  be  of  benefit. 

In  nervous  vomiting,  as  in  nervous  dyspepsia,  the  same 
principles  governing  the  hydrotherapeutic  and  balneological 
therapy  are  applicable.  Since  in  almost  all  cases  we  are 
dealing  with  an  irritable  form  of  neurosis,  prolonged  residence 
at  the  northern  seaside  is  generally  inadvisable,  although  re- 
sorts along  the  Mediterranean  may  sometimes  be  recommended. 

CLINICAL  CASES 
Case  1. — In  the  case  of  Frieda  F.,  19  years  old,  the  daughter  of  a  mid- 
wife, menstruation  wliich  had  begun  at  the  age  of  16  had  been  irregular. 
For  one  year  there  had  been  sluggishness  of  the  bowels,  and  for  five  weeks 
previous,  the  patient  had  been  obliged  to  use  enemata  because  purgative 
remedies  had  become  ineffectual.  For  five  months  patient  had  had  loss  of 
appetite,  pressure  in  the  stomach  after  heavy  meals,  and  often  vomiting 
after  eating,  which  had  recently  occurred  several  times  daily.  Patient  was 
fairly  well  nourished.  The  habitus  enteropticus  was  present.  The  appendix 
was  palpable.     Otherwise  the  physical  examination  was  negative. 


214  DISEASES  OF  THE  DIGESTIVE  CANAL 

Treatment. — The  therapy  consisted  in  suggestive  treatment  and  mas- 
sage which  was  called  "magnetism,"  also  belladonna  and  codeine  pills,  and  a 
heavy  constipation-diet,  in  spite  of  which  no  pressure  in  the  stomach  or  vomit- 
ing occurred.  After  two  and  one-half  weeks,  the  patient  could  bear  the 
heaviest  diet  without  the  use  of  narcotics.  Massage  was  continued  and  endo- 
faradization  begun.  After  three  treatments  of  the  latter,  the  stools  were 
evacuated  spontaneously,  since  which  time  the  patient  has  been  entirely  well. 

Case  2. — Emma  R.,  34  years  old,  the  daughter  of  an  army  officer, 
had  suffered  from  chlorosis  and  occasional  stomach-trouble  for  the  past  few 
years.  For  two  weeks  jDrevious,  the  patient  had  loss  of  api^etite,  vertigo, 
and  persistent  vomiting  immediately  after  eating.  Only  slight  interruptions 
in  the  vomiting  spells  occurred,  followed  by  some  improvement.  The  patient 
had  constant  ]:)ressure  in  the  stomach,  but  no  pain.  She  was  of  slight  phy- 
sique, had  the  habitus  cnteropticus,  a  small  goitre,  and  a  movable  right  kidney. 
Bromides  and  faradization  were  ineffective.  I\Iassage  was,  therefore,  sub- 
stituted, which  proved  of  great  benefit.  For  instance,  she  was  soon  able  to 
eat  such  food  as  herring  and  potatoes  without  any  discomfort.  In  the  course 
of  five  years,  during  which  time  she  was  under  observation,  she  had  only  two 
periods  of  vomiting,  which  were  removed  each  time  by  effleurage  of  the  epigas- 
trium, and  verbal  suggestion.     The  total  acidity  of  the  gastric  juice  was  46. 

Case  3. — Gertrude  P.,  a  sales-girl,  16  years  old,  gave  a  history  of 
sexual  perversion  and  early  sexual  relations.  She  had  had  gonorrhoea  and 
had  been  subject  to  severe  mental  strain.  For  one  or  two  years,  the  patient 
had  at  periods  vomited  everything  she  had  eaten,  immediately  after  meals, 
and  had  felt  severe  pressure  in  the  stomach.  She  had  been  treated  unsuc- 
cessfully for  ulcer  several  times.  Patient  was  well  nourished.  She  had  the 
habitus  enter opticxis.  The  acidity  of  the  test-breakfast  was  normal,  total 
acidity  being  64.  After  one  week  of  daily  massage,  softly  stroking  the  epi- 
gastrium, the  pressure  in  the  stomach  and  the  vomiting  completely  ceased, 
and  the  patient  was  able  to  eat  meat,  potatoes,  etc.,  without  any  discomfort. 
Her  health  remained  normal  for  several  months,  at  which  time  she  suffered 
a  relapse,  and  was  again  cured  by  the  same  treatment.  Later  on,  the  patient 
developed  hysterical  writer's  cramp,  for  which  she  was  treated  two  months 
with  cold  baths,  etc.,  in  a  sanitarium  for  nervous  diseases.  The  writer's 
cramp  disappeared  but  the  patient  still  complained  of  pressure  in  the  stomach, 
which  was  again  removed  by  one  week's  treatment  with  massage.  The 
condition  subsequentl)^  recurred,  associated  again  with  writer's  cramp,  for 
which  she  was  again  sent  to  a  sanitarium. 

2.  Gastric  Vertigo 

B)^  the  term  ''gastric  vertigo"  is  understood  the  frequent 
occurrence  of  a  feeling  of  dizziness  about  the  end  of  the 
mealtime. 


DISEASES  OF  THE  STOMACH  215 

It  is  most  commonly  observed  in  young  persons  who  are 
extremely  nervous,  in  consequence  of  masturbation  or  other 
causes.     Except  for  this  symptom,  the  patients  feel  well. 

The  objective  signs  of  the  stomach  are  negative.  The 
secretion  shows  normal  or  fluctuating  values.  Motility  is  normal. 

The  diagnosis  is  made  from  the  history  of  the  subjective 
disturbances  and  from  the  negative  objective  findings. 

The  prognosis  is  favorable.  The  affection  generally 
disappears  soon  after  the  causal  factors  have  been  removed. 

Therapy. — The  therapy  consists  in  the  abolition  of  those 
factors  which  have  weakened  the  nervous  system,  the  admin- 
istration of  bromide  and  valerian  preparations,  massage  of 
the  entire  body,  and  the  employment  of  half-baths.  If  the 
condition  occurs  in  a  patient  with  poor  nutrition,  a  mild  fat- 
tening-diet  is  indicated. 

CLINICAL    C4SES 

Case  1. — Julius  S.,  a  joiner,  55  years  old,  had  had  influenza  for  three 
years,  and  for  two  years  had  suffered  from  stomach-trouble,  a  feeling  of 
dizziness  and  loud  eructations  after  each  meal.  He  had  no  pain,  his  appetite 
was  poor,  and  he  was  ill-nourished.  Stools  were  irregular;  and  he  frequently 
complained  of  pressure  in  the  head.  The  test-breakfast  showed  a  slight  sub- 
acidity.  x\fter  treatment  with  bromide  and  valerian  tea,  the  patient 
improved. 

Case  2. — Marie  V.,  40  years  old,  had  been  healthy  up  to  three  months 
previous,  since  which  time  she  had  suffered  from  heartburn  and  a  feeUng  of 
vertigo,  generally  one  hour  after  a  meal,- — even  of  liquids.  If  she  had  suf- 
ficient rest  the  above  symptoms  did  not  appear ;  but  they  invariably  retiirned 
after  hard  labor.  The  patient's  bowels  moved  once  or  twice  a  day;  stools 
were  soft.    The  appetite  was  good. 

Physical  Examinolion. — Patient  was  pale  and  emaciated;  the  right 
kidney  was  palpable.  Total  acidity  of  the  test-breakfast  was  30.  After 
treatment  with  bromides  the  patient  improved.  Oxyuria  had  been  noted 
in  the  stools  for  the  past  three  months,  therefore  the  case  was  not  a  simple 
gastric  neurosis,  but  reflex  vertigo. 

3.  Nervous  Anorexia 

Great  variations  in  the  appetite  may  occur  from  purely 
nervous  influences;  it  may  be  considerably  increased  or 
totally  lost. 


216  DISEASES  OF  THE  DIGESTIVE  CANAL 

Bulimia  (ox-hungcr),  or  c  y  n  o  r  c  x  i  a  ,  hj  which  is 
meant  an  abnormal  increase  of  the  feeling  of  hunger,  occurs 
quite  frequently. 

The  fundamental  reason  for  this  condition  is  probably 
an  abnormal  increase  in  the  motility  of  the  stomach  whereby 
its  contents  are  propelled  into  the  tluodenum  in  considerably 
less  than  the  normal  time. 

Such  patients  experience  an  imperative  need  of  food, 
which,  if  not  gratified,  results  in  phenomena  resembling  an 
attack  of  fainting,  which  disappear  immediately  after  eating. 

The  actual  cause  of  the  affection  is  unknown. 

The  prognosis  is  not  especially  favorable,  since  the  trouble 
will  often  persist  many  3^ears,  and  causes  exceeding  discomfort 
and  annoyance. 

Every  case  of  bulimia  should  naturally  be  examined  for 
diabetes,  since  a  ravenous  appetite  is  often  the  first  symptom 
of  this  disease. 

Gastralgokenosis. — Closely  associated  with  this  affection 
is  the  so-called  '^ gastralgokenosis,"  a  form  of  gastric  neurosis 
which  was  introduced  into  the  pathology  of  the  stomach  by 
Boas,  and  is  characterized  by  a  painful  emptiness  of  the 
stomach. 

Patients  with  this  affection  do  not  experience  the  same 
insane,  irresistible  desire  to  eat  as  do  those  with  bulimia; 
but  several  hours  after  meals  an  unpleasant  feeling  of  con- 
traction in  the  pit  of  the  stomach  occurs,  which  disappears 
immediately  after  taking  any  kind  of  food.  This  symptom 
is  very  frequently  considered  as  '^ heart-pain"  by  the  laity. 

Patients  suffering  from  gastralgokenosis  feel  a  need  to 
eat,  yet  lack  the  desire.  They  have  an  abnormal  feehng  of 
hunger  but  no  appetite. 

This  neurosis  need  not  be  confused  with  ulcer  or  erosions 
of  the  pylorus,  in  which  severe  pain  occurs  several  hours  after 
eating, — so-called  epigastralgia, — which  immediately  disap- 
pears after  taking  food  or  drink. 

Whenever  a  cramp-like  pain  occurs  at  a  definite  time 
after  meals,  the  examiner  should  always  think  of  an  ulcer 


DISEASES  OF  THE  STOMACH  217 

associated  with  hyperchlorhydria, — which  has  been  discussed 
in  detail  in  the  section  on  Gastric  Ulcer. 

Treatment. — Gastralgokenosis  may  be  easily  and  suc- 
cessfully treated  by  having  the  patient  eat  every  two  or  three 
hours,  thereby  removing  the  factors  of  malnutrition  and 
ansemia,  when  the  condition  will  disappear  of  itself. 

In  contradistinction  to  this,  the  physician  is  quite  help- 
less in  the  treatment  of  bulimia.  In  individual  cases,  arsenic 
and  silver  nitrate  offer  good  service. 

1.  T^     Liquoris  potassii  arsenitis, 

Aqu£e  menthse  piperitse,  aa,  5iiss     10.0 
M.  Sig. — Six  to  ten  drops  after  meals,  t.i.d.    Add 
one  drop  to  the  dose  each  week. 

2.  I^     Argenti  nitratis,  gr.  vi       0.4 

AquEB,  oviss  200.0 

M.  Sig.- — A  tablespoonful  (porcelain)  in  a 
wineglassful  of  water  fifteen  minutes 
before  meals. 

Nervous  Anorexia.— In  contrast  to  bulimia  is  nervous 
anorexia,  or  total  loss  of  appetite. 

Before  the  examiner  makes  a  diagnosis  of  nervous  ano- 
rexia, it  is  necessary  first  to  exclude  other  diseases  of  the 
stomach  or  of  other  organs  which  produce  the  same  symptom, 
especially  incipient  tuberculosis,  early  carcinoma  of  the 
stomach  or  other  organs,  typhoid  fever,  Basedow's  disease,  etc. 

Etiology. — The  causes  of  nervous  anorexia  are,  as  a  rule, 
emotional  disturbances  from  bereavement,  loss  of  property, 
fright,  railroad  and  steamship  accidents,  etc. 

A  patient  suffering  from  nervous  anorexia  may  become 
considerably  emaciated,  losing  as  much  as  fifty  pounds  or 
more,  so  that  the  suspicion  of  the  presence  of  a  malignant 
neoplasm  will  at  first  occur  to  the  examiner. 

The  other  functions  of  the  stomach, — secretion  and 
motility, — are  either  quite  normal  or  offer  variations  typical 
of  nervous  dyspepsia.  Frequently  there  is  a  marked  dimi- 
nution in  the  amount  of  hydrochloric  acid  in  the  gastric  juice 
which  renders  the  differential  diagnosis  between  nervous  ano- 
rexia and  latent  carcinoma  of  the  stomach  especially  difficult. 


218  DISEASES  OF  THE  DIGESTIVE  CANAL 

It  is  not  at  all  rare  for  hyperchlorhydria  to  be  associated 
with  nervous  anorexia. 

Treatment. — The  therapy  consists  in  the  administration 
of  bitters.    The  following  have  proven  useful  in  my  experience: 

Fluid  extract  of  quinine,  20  drops  before  meals,  t.i.d. 
Tincture  of  gentian,  or  rhubarb,  a  teaspoonful  before  meals,  t.i.d. 
Fluid  extract  of  calamus,  a  teaspoonful  before  meals,  t.i.d. 
Orexin,  4  or  5  grains  (0.3)  in  capsules,  t.i.d. 

In  most  cases,  a  change  of  scene  is  essential,  though  not 
to  any  special  health  resort,  it  being  sufficient  for  the  patient 
to  go  to  any  kind  of  summer  resort  or  to  visit  relatives  in 
the  country  or  at  the  seashore,  or  to  go  anywhere  that  offers 
the  necessary  change  and  diversion,  for  in  this  affection  we 
almost  always  have  to  do  with  a  depressed  condition  of  the 
nervous  system. 

Acoria. — By  way  of  addendum,  I  will  mention  the  condi- 
tion known  as  acoria,  a  neurosis  in  which  the  patient  has  lost 
the  sense  of  satiation  of  hunger. 

The  condition  is  encountered  especially  often  in  women 
in  the  climacteric. 

The  treatment  of  acoria  is  wholly  ineffectual,  and  it  often 
exists  for  several  years.  The  therapy  is  largely  limited  to  send- 
ing the  patient  to  a  health  resort,  administering  symptomatic 
remedies,  and  waiting  for  the  neurosis  to  disappear  of  itself. 

CLINICAL    CASES 

Case  1. — Dora  P.,  an  artist,  54  years  old,  had  for  ten  years  had  attacks 
of  nausea,  gnawing  pain  in  the  epigastrium,  and  vomiting  of  water  during 
periods  occurring  from  two  to  four  times  each  year.  The  appetite  was  good, 
but  the  patient  was  afraid  to  eat.  The  attacks  occurred  only  after  she  had 
not  eaten  for  several  hours,  and  were  usually  terminated  by  the  regurgita- 
tion of  liquids.  The  patient  had  several  times  been  treated  for  tapeworm. 
She  had  been  constipated  from  twenty  to  thirty  years,  and  had  been  under 
a  severe  nervous  strain  in  caring  for  her  paralytic  husband. 

Patient  was  pale,  poorly  nourished,  had  the  normal  habitus,  and  relaxed 
abdomen;  the  right  kidney  was  movable  to  the  second  degree;  the  transverse 
colon  and  the  sigmoid  flexure  were  contracted  and  palpable.  There  were  no 
symptoms  pointing  to  disease  of  the  central  nervous  system.  The  test-break- 
fast showed  the  stomach-contents  to  be  normal,  the  total  acidity  being  54. 


DISEASES  OF  THE  STOMACH  219 

Treatment  consisted  in  the  administration  of  belladonna  pills  and  a 
constipation-fattening  diet,  with  oil  enemata  twice  a  week.  After  two 
weeks  of  treatment,  the  stools  were  spontaneous  and  the  painful  emptiness 
of  the  stomach  and  the  vomiting  of  water  had  entirely  ceased.  During 
the  following  few  months,  the  patient  increased  twenty  pounds  in  weight, 
and  remained  in  good  health. 

Case  2. — Pauline  C,  a  dancer,  30  years  old,  had  had  occasional 
stomach-trouble  during  her  childhood,  after  which  period  she  had  been 
healthy  until  one  year  previous,  since  which  time  she  had  had  considerable 
discomfort  in  the  epigastrium  several  hours  after  a  meal,  which  would  cease 
immediately  after  eating  even  a  mouthful  of  food.  Patient  had  occasionally 
vomited  mucus.  There  had  been  a  loss  of  ten  pounds  in  weight.  Some  days 
the  patient  had  felt  free  from  the  symptoms.  On  account  of  her  occupation, 
she  had  been  irregular  in  her  meals  for  several  years.  Examination  showed 
that  she  was  emaciated  and  had  habitus  enter  opticus.  She  was  treated  with 
bromides  and  valerian  without  results.  The  test-breakfast  was  normal, 
total  acidity  being  50.  The  painful  emptiness  of  the  stomach  frequently 
recurred,  and  improvement  was  obtained  only  after  prescribing  the  ulcer- 
diet  and  the  use  of  mastication  tablets ;  so  in  this  case  there  probably  existed 
an  ulcer  of  the  stomach  rather  than  a  gastric  neurosis. 

Case  3. — Anna  R.,  a  house\yife,  28  years  old,  had  for  two  and  one- 
half  months  suffered  from  painful  contracting  sensations  in  the  epigastrium 
whenever  the  stomajch  became  empty, — these  attacks  generally  occurring 
early  in  the  morning  and  at  2:00  or  3:00  o'clock  in  the  afternoon,  as  the 
patient  did  not  eat  anything  between  the  hours  of  8:00  o'clock  in  the 
morning  and  3:00  o'clock  in  the  afternoon.  Soon  after  eating,  the  pains 
disappeared.  After  treatment  with  belladonna,  valerian,  and  regulation  of 
the  diet,  improvement  occurred  without  resorting  to  treatment  for  ulcer. 

Case  4. — Clara  H.,  a  capitahst,  46  years  old,  had  had  an  operation  for 
hemorrhoids  seven  years  previous.  For  five  years  the  patient  had  never  ex- 
perienced the  sensation  of  satiation  of  hunger.  Improvement  resulted  from 
treatment  at  Franzensbad,  which  was  followed  by  a  recurrence  of  symptoms, 
and  the  weight  was  reduced  from  168  to  110  pounds.  At  the  time  of  the  ex- 
amination, the  patient  was  constipated,  and  the  appetite  poor,  but  hunger 
was  not  appeased  by  eating.  She  was  treated  with  belladonna,  etc.,  and  with 
massage  to  regulate  the  bowels.  The  acoria  was  not  influenced  by  treatment. 
Observation  of  the  patient  gave  the  impression  that  she  was  hysterical. 

Nervous  Hyperacidity,  Subacidity  and  Anacidity 

In  the  section  on  Nervous  Dyspepsia,  it  was  stated  that 
the  gastric  secretions  might  be  increased,  diminished  or  entirely 
lost  through  purely  nervous  influences.  The  subject  merits, 
therefore^  a  somewhat  detailed  consideration. 


220  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  diagnosis  of  an}'  of  these  conditions  is  possible  only 
after  a  prolonged  observation  of  the  patient. 

In  the  differential  diagnosis  of  nervous  hyperacidity, 
the  physician  should  especially  eliminate  acid  gastritis  and  gas- 
tric ulcer.  A  detailed  consideration  of  the  differential  points 
has  already  been  given  in  the  chapter  on  Hyperchlorhyclria. 

In  making  the  diagnosis  of  nervous  anacidity,  this  affec- 
tion is  most  likely  to  be  confused  with  anacid  gastritis  and 
incipient  carcinoma.  The  chapter  on  Nervous  Dyspepsia 
presents  the  question  in  detail. 

Many  authors  assume  that  total  achylia  may  occur  on 
a  purely  nervous  basis  and  that  the  functions  of  the  gastric 
glands  are  depressed  even  to  complete  cessation  in  the  pro- 
duction of  the  gastric  ferments,  without  being  associated  with 
any  anatomical  change  of  the  mucosa. 

In  my  opinion,  this  is  an  error.  An  anatomical  process  is  probably 
always  the  cause  of  a  diminution  in  the  total  acidity  of  the  test-breakfast, 
when  it  is  as  low  as  from  6  to  8. 

It  is  not  essential  to  account  for  such  diminution  by  an  alcoholic  gas- 
tritis alone,  since  a  parenchymatous  inflammation  of  the  gastric  mucous 
membrane  may  arise  from  other  causes,  such  as  years  of  privation,  hasty, 
irregular  eating,  bad  teeth,  and  the  misuse  of  laxatives. 

The  total  acidity  of  a  purely  nervous  anacidity  is  rarely 
found  to  be  below  18.  There  is  an  absence  of  only  free  hydro- 
chloric acid.    The  combined  acids  and  the  ferments  are  present. 

The  treatment  is  that  of  the  primary  disease,  as  in  ner- 
vous dyspepsia. 

In  hyperacidity,  the  belladonna  preparations  are  indi- 
cated; and  in  subacidity  and  anacidity,  strychnine,  as  in  the 
following  prescriptions : 

1.  I^     Tinctura^  belladonnse  foliorum,  oiiss     10.0 

Tincturse  Valerianae,  5v  20.0 

M.  Sig. — Twenty-five  drops,  t.i.d. 

2.  I^     Tincturse  nucis  vomicae,  oiiss  10.0 

Tincturae  rhei,  ov  20.0 

M.  Sig. — Twenty-five  drops,  t.i.d. 

Hypersecretion  is  also  held  by  some  authors  to  be  a 
nervous  affection,  especially  by  Riegel  and  his  school,   who 


DISEASES  OF  THE  STOMACH  221 

assume  that  the  gastric  glands  respond  to  purely  nervous 
influences  with  an  alimentary  hypersecretion  in  slight  cases,  and 
with  continuous  secretion  of  gastric  juice  in  more  severe  cases. 

According  to  the  view  held  by  the  majority  of  author.s,  hypersecretion 
is  always  of  an  organic  nature  and  rightfully  belongs  to  the  chapters  which 
discuss  Acid  Gastritis  and  Stenosis  of  the  Pylorus. 

The  gastric  glands  become  irritated  and  hypertrophied,  and  respond 
with  a  continuous  hypersecretion  of  gastric  juice,  from  the  irritating  effect 
of  poisons,  alcohol,  nicotine,  excessive  meat-eating,  and  over-eating.  The 
glands  of  the  stomach  are  subject  to  the  same  irritation  if  stagnation  of  the 
stomach-contents  results  from  stenosis  of  the  pylorus  caused  by  scars  or  ulcer. 

If  the  irritation  of  the  gastric  glands  is  removed, — as  may  result  from 
suitable  treatment,  from  the  healing  of  the  ulcer,  or  by  gastro-enterostomy, — 
the  glands  gradually  resume  their  normal  functions. 

It  very  often  requires  years,  however,  to  bring  this  about,  since  the 
causative  factors  have  also  been  operative  for  many  years. 

Nervous  Cardiospasm  and  Pylorospasm 

The  diagnosis  of  these  conditions  is  very  often  wrongly 
made  in  general  practice.  As  has  been  mentioned  in  discuss- 
ing the  differential  diagnosis  of  Gastric  Ulcer,  all  kinds  of 
affections  are  diagnosticated  under  these  terms;  while  as  a 
matter  of  fact,  spasm  of  the  cardia  or  of  the  pylorus  very 
rarely  occurs  as  a  neurosis. 

Generally  the  conditions  taken  for  cardio-  and  pyloro- 
spasm are  cases  of  gall-stone  colic,  gastric  crises  of  tabes, 
angina  pectoris,  intestinal  colic  and — the  most  frequently — 
ulcer  of  the  pylorus  associated  with  hyperchlorhydria. 

My  opinion  is,  that  there  is  practically  no  nervous  affec- 
tion of  the  stomach  in  which  actual  pain  is  a  symptom.  When- 
ever a  pain  does  occur,  the  physician  should  always  think  of 
an  organic  lesion  of  the  mucous  membrane  of  the  stomach. 
Although  there  are  certain  unpleasant  sensations  in  the  epigas- 
trium in  neurasthenia  and  in  nervous  dyspepsia,  neither  actual 
pain  nor  cramps  ever  occur.  The  absence  of  real  pain,  in  fact, 
differentiates  functional  from  organic  disease  of  the  stomach. 

If  pain  suddenly  occurs  as  a  symptom  in  a  patient  who 
has  been  suffering  from  a  nervous  affection  of  the  stomach 
for  years,  the  physician  should  at  once  think  of  a  complica- 


222  DISEASES  OF  THE  DIGESTIVE  CANAL 

tion.  For  example,  I  saw  a  case  of  severe  neurasthenia  with 
hyperacidity  which  had  for  years  presented  symptoms  of 
nervous  dyspepsia, — loss  of  appetite,  pressure  and  fulness  after 
eating,  etc.  Gastralgia  suddenly  developed,  occurring  several 
hours  after  meals.  It  was  pronounced  by  a  specialist  to  be  due 
to  a  nervous  affection  of  the  stomach,  and  was  so  treated. 
The  sudden  occurrence  of  hsematemesis,  however,  gave  evidence 
of  the  true  nature  of  the  affection,  namely,  gastric  ulcer. 

The  somewhat  exceptional  association  of  an  organic 
disease  of  the  stomach  with  nervous  dj^spepsia  was  charac- 
teristic of  this  case. 

I  must  state  that  I  have  never  yet  observed  an  undoubted 
case  of  nervous  spasm  of  the  pylorus  or  cardia. 

Painful  cardiospasm  is  generally  caused  by  some  organic 
lesion,  such  as  small  erosions  of  the  mucous  membrane  around 
the  cardia.  When  otherwise  caused,  the  symptoms  produced  by 
the  spasm  are  more  like  unpleasant  sensations  in  s  wallo  wing-than 
actual  pain.    [See  discussion  of  chronic  cardiospasm,  page  61.] 

CLINICAL    CASE 

Rosalie  G.,  48  years  old,  had  given  birth  to  nine  children,  and  had 
been  subject  to  much  grief  and  care, — her  husband  being  an  inmate  of  an 
asylum.  Menstruation  had  been  irregular.  For  two  years,  the  patient  had 
had  a  feehng  of  contraction  in  the  epigastrium  every  ten  or  fifteen  minutes, 
which  was  independent  of  eating.  Patient  had  never  vomited,  and  the 
bowels  had  been  fairly  regular.  She  was  considerably  emaciated,  had  habitus 
enter ojiticus,  and  relaxed  abdomen.  The  pylorus  was  palpable,  of  about  the 
size  of  a  walnut,  and  was  felt  by  the  palpating  hand  to  be  alternately  soft 
and  hard.  Both  the  secretions  and  the  motility  of  the  stomach  were  normal. 
Patient  made  temporary  improvement  under  bromides,  valerian,  and  mas- 
sage, during  which  time  she  increased  in  weight  and  felt  no  discomfort. 
After  renewed  trouble  and  worry,  the  above  symptoms  always  returned. 
Patient  was  seen  five  years  after  the  first  examination,  and  was  in  practically 
the  same  condition;  so  that  malignant  or  benign  stenosis  of  the  pylorus 
could  be  excluded  in  this  case. 

With  this  I  close  the  discussion  of  Functional-Nervous 
Affections  of  the  Stomach.  They  are  extremely  diverse  in 
their  manifestations;  and  the  art  of  the  physician,  his  ability 
to  improvise,  and  his  ingenuity  in  the  treatment  and  manage- 


DISEASES  OF  THE  STOMACH  223 

ment  of  these  cases,  find  a  large  field  in  this  form  of  dyspepsia. 
Those  of  the  largest  experience  in  these  cases  will  naturally 
obtain  the  greatest  number  of  cures. 

It  may  be  mentioned  once  again  that  in  doubtful  cases  the 
patient  should  at  first  be  treated  as  if  he  had  an  organic  disease 
of  the  stomach;  and  only  after  this  method  of  treatment  has 
been  unattended  with  favorable  results  should  the  affection  be 
assumed  to  be  a  neurosis  and  general  treatment  instituted. 

DISEASES  OF  THE  STOMACH  IN  CONNECTION  WITH  DISEASES 
OF  OTHER  ORGANS 

Stomach-Affections  Secondary  to  Diseases  of  Other  Organs  of  the  Body 
(Symptomatic  Affections  of  the  Stomach) 

Although  the  relationship  between  diseases  of  the  stomach 
and  constitutional  diseases  and  affections  of  other  organs  of  the 
body  has  been  mentioned  quite  often  in  the  foregoing  chapters, 
there  are  a  few  especially  frequent  and  important  reflex  stom- 
ach-conditions that  should  be  individually  considered. 

1.  The  Stomach  and  Disorders  of  Metabolism 

Anaemia  very  frequently  produces  dyspepsia,  as  we  have 
seen  in  the  section  on  Functional  Diseases  of  the  Stomach, 
no  matter  what  the  origin  of  the  anaemia  is;  and  especially, 
if  enteroptosis  and  malnutrition  are  associated  conditions. 

Pernicious  anaemia, — or  any  other  form  of  wasting 
disease, — such  as  carcinoma  of  any  of  the  internal  organs, — 
frequently  causes  atrophy  of  the  gastric  glands. 

In  regard  to  anaemia,  it  is  also  true  that  the  atrophy  of 
the  gastric  glands  may  be  primary,  and  pernicious  anaemia 
the  secondary  affection,  if  at  the  same  time  the  absorptive 
ability  of  the  small  intestine  is  much  impaired. 

Anaemia  leads  only  exceptionally  to  anatomical,  but 
very  frequently  to  functional,  disturbances  of  the  stomach. 

In  regard  to  the  diagnosis  and  treatment,  the  reader  is 
referred  to  the  chapter  on  Anaemic-Gastroptotic  Dyspepsia, 
for  the  details. 

Chlorosis  is  frequently  associated  with  organic  affections 
of  the  stomach,  such  as  erosions  and  ulcers.    It  is  only  in  the 


224  DISEASES  OF  THE  DIGESTIVE  CANAL 

minority  of  cases,  however,  that  such  comphcations  as  per- 
foration, adhesion,  cicatricial  formation,  and  stenosis  of  the 
pylorus  occur;  for  the  reason  that  only  small  superficial 
breaks  in  the  continuity  of  the  mucous  membrane  of  the 
stomach   are   present,    which   heal   without   scar-formation. 

This  explains  why  it  is  that,  in  proportion  to  the  fre- 
quency of  ulcer,  fewer  women  are  affected  with  stenosis  of  the 
pylorus  and  secondary  dilatation  of  the  stomach  than  men,  in 
whom  ulcers  arise  from  other  causes,  such  as  chronic  gastritis 
and  compression  of  the  epigastrium  in  various  occupations. 

In  chlorotic  dyspepsia,  especially  in  young  girls,  the 
symptoms  are  often  very  vague  and  indefinite;  at  one  time 
there  is  pain,  at  another  time  pressure,  and  at  still  another 
time,  burning  in  the  epigastrium,  which  in  most  cases  the 
physician  will  be  able  to  ascribe  to  chlorotic  erosions  of  the 
mucosa.  These  disturbances,  as  a  rule,  are  stubborn  to  treat- 
ment, persisting  often  two  or  three  years,  and  disappearing 
only  with  the  chlorosis. 

The  treatment  does  not  differ  in  any  way  from  that  of 
ordinary  ulcer.  It  should  consist  in  the  administration  of 
silver  nitrate,  as  long  as  pain  is  present  in  the  epigastrium. 
No  iron  should  be  given  until  all  local  gastric  symptoms  have 
disappeared.  It  is  preferable  to  send  patients,  who  can  afford 
the  expense,  to  some  chalybeate  spring,  such  as  Flinsberg, 
Pyrmont,  etc.  [Sharon  Chalybeate  Spring,  Schoharie  County, 
N.  Y.,  Churchill  Alum,  Virginia,  Cresson  Alum  Springs, 
Pennsylvania,  Santa  Clara  Vichy,  Cahfornia.] 

It  is  well  known  that  diabetes  very  frequently  causes 
dyspeptic  symptoms, — especially  acoria,  ravenous  appetite, 
and  disagreeable  fetor  ex  ore. 

Stomach  disturbances  are  frequently  associated  with 
gout  and  obesity.  Hyperchlorhydria  with  its  symptoms  is 
usually  present  with  the  former;  while  pyrosis  and  burning 
pains  in  the  stomach  and  the  symptoms  of  acid  gastritis  are 
usually  present  in  obesity,  as  a  result  of  immoderate  eating. 

The  treatment  of  all  these  conditions  is  that  of  the  pri- 
mary disease,  the  details  of  which  cannot  be  entered  into  here. 


DISEASES  OF  THE  STOMACH  225 

2.  Acute  Infectious  Diseases 

Gastric  symptoms,  loss  of  appetite,  and  vomiting  occur 
especially  often  in  meningitis,  scarlet  fever,  influenza,  and 
typhoid  fever. 

The  vomiting  is  usually  reflex,  while  the  loss  of  appetite 
is  due  to  the  febrile  process,  although  it  is  often, — for  instance, 
in  influenza, — an  expression  of  an  acute  parenchymatous 
gastritis  which  is  demonstrable  at  autopsy. 

3.    Chronic  Infectious  Diseases 

Tuberculosis  of  the  lungs  frequently  causes  disturbances 
of  gastric  digestion,  as  has  already  been  mentioned  in  detail 
in  the  chapter  on  Phthisical  Dyspepsia.  Tubercular  lesions 
limited  to  the  mucous  membrane  of  the  stomach  are  very  rare. 

Syphilitic  lesions  are  also  very  rarely  found  in  the  stomach, 
although  syphilitic  ulcers  are  now  and  then  found  post  mortem. 

Specific  affections  of  neighboring  organs,  such  as  the 
liver  and  the  lymphatic  glands  accompanying  the  portal  vein, 
may  indirectly  produce  gastric  disturbances  by  narrowing 
the  pyloric  outlet  and  by  producing  jaundice. 

The  well-known  gastric  crises  of  tabes,  and  the  dyspepsia 
associated  with  paralysis,  may  also  be  mentioned.  It  should 
be  recalled,  as  well,  that  nervous  dyspepsia  is  often  caused 
directly  from  fear  of  syphilitic  infection. 

4.   Central  Nervous  System 

The  relationship  between  diseases  of  the  stomach  and  dis- 
turbances of  the  sympathetic  nervous  system  has  been  suggested 
in  the  chapters  on  Nervous  Dyspepsia  and  Gastric  Neuroses. 

The  important  association  existing  between  diseases  of 
the  stomach  and  the  central  nervous  system  should  also  be 
considered. 

The  very  frequent  occurrence  of  vomiting  in  diseases  of 
the  brain, — particularly  in  meningitis,  and  cerebral  tumors, — 
is  well  established.  Cerebral  vomiting  is  characterized  by  its 
occurring  independently  of  the  nature  of  the  food;    and  it  is 

15 


226  DISEASES  OF  THE  DIGESTIVE  CANAL 

particular!}'  likely  to  occur  whenever  the  patient  assumes  an 
upright  position. 

The  correct  diagnosis  is  usually  possible  from  the  associ- 
ation of  symptoms,  or  if  the  physician  is  able  to  prove  that 
the  functions  of  the  stomach  are  normal. 

I  recently  had  occasion  to  observe  a  patient  who  vomited  profusely 
whenever  he  assumed  an  upright  position.  While  one  would  at  first  naturally 
think  of  carcinoma  of  the  pjdorus,  the  microscopical  examination  of  the 
contents  of  the  stomach  showed  that  no  stagnation  of  food  existed, — which 
therefore  excluded  the  existence  of  pyloric  stenosis.  Free  hydrochloric 
acid  was  present,  but  neither  sarcinse  nor  lactic  acid  bacilli.  From  the 
associated  symptoms,  therefore,  I  made  a  diagnosis  of  cerebral  vomiting. 
The  patient,  a  man  about  fifty  years  old,  died  soon  afterwards,  and  a 
cerebral  tumor  was  found  at  autopsy. 

The  vomiting  which  results  from  disease  of  the  fifth 
nerve  may  also  be  properly  mentioned  here.  Headache  usually 
precedes  vomiting  in  these  cases,  as  in  the  wTll-known  symp- 
tom-complex of  migraine. 

Less  often  recognized  is  the  fact  that  gastric  crises  may 
be  the  first  symptom  of  locomotor  ataxia;  the  loss  of  the 
patellar  reflexes,  and  the  presence  of  the  Argyll-Robertson 
pupil  not  being  evident  until  two  or  three  years  later.  The 
crises  usually  occur  in  patients  with  a  syphilitic  history  who 
have  had  insufficient  medication,  or  none  at  all.  In  almost 
every  case,  examination  reveals  the  scar  of  a  venereal  ulcer. 
The  gastric  crises  usually  occur  six  to  seven  years  after  the 
specific  infection,  although  I  have  seen  cases  in  which  the 
crises  developed  in  two  or  three  years. 

The  gastric  crises  are  characterized  by  periodical  attacks 
of  vomiting  all  food.  These  attacks  are  often  accompanied 
by  most  severe  pain.     Later,  mucus  and  bile  are  vomited. 

Every  case  of  periodical  vomiting  should  be  examined 
for  tabes. 

In  some  instances,  the  gastric  crises  recur  every  month,  lasting  two 
or  three  days;  while  in  other  cases  they  return  at  intervals  of  months 
or  even  years;  and  in  still  other  cases  they  disappear  permanently  after 
two  or  three  paroxysms.     The  occurrence  of  gastric  crises  is  at  present 


DISEASES  OF  THE  STOMACH  227 

unaccounted  for.  Following  an  attack,  the  patient  is  again  entirely  well 
and  digests  everything  he  eats,  just  as  if  he  had  never  experienced  any 
stomach-trouble . 

The  diagnosis  is  generally  easy,  although  mistakes  are 
frequent,  because  the  true  nature  of  the  disease  is  unsuspected 
by  the  examiner. 

The  treatment  is  unsatisfactory. 

If  the  attacks  occur  from  five  to  seven  years  after  infec- 
tion, mercurial  inunctions  followed  by  iodide  treatment 
should  be  tried.  Generally,  however,  it  is  then  too  late  to  be 
successful.  In  doubtful  cases,  the  decision  as  to  whether 
specific  treatment  should  be  instituted  would  better  be  left 
to  the  opinion  of  an  expert  neurologist. 

Symptomatic  treatment  consists  in  the  use  of  strychnine, 
morphine  and  other  narcotics.  The  following  prescriptions 
will  be  found  serviceable: 

1.  T^     Cerii  oxalatis,  gr.  |-iss  0.5-0.1 
Sig.— T.i.d. 

2.  I^     Morphinse  hydrochloridi,  gr.  J      0.02 
Sig.— T.i.d. 

3.  I^     Atropinje  sulphatis,  gr.  jh^  0.0005 

CLINICAL    CASES 

Case  1. — Constantino  G.,  a  waiter.  35  years  old,  had  a  chancre  eighteen 
years  previously,  which  was  treated  by  injections.  He  had  gonorrhoea  several 
times,  and  for  three  years  had  had  attacks  about  once  in  two  months  when 
he  vomited  everything  he  ate,  in  addition  to  bile,  and  suffered  from  violent 
pains  in  the  epigastrium,  head,  and  chest.  These  attacks  usually  lasted  for 
about  seven  days.  In  the  intervals,  patient  ate  and  digested  all  foods  without 
discomfort.  The  bowels  were  regular,  except  that  two  days  previous  to  the 
attack  there  was  always  constipation.  The  examination  showed  the  patient 
to  be  well  nourished.  He  had  exophthalmus,  the  Argyll-Robertson  pupil, 
slight  ataxia,  and  the  loss  of  the  patellar  reflexes.  The  secretory  and  motor 
functions  of  the  stomach  were  normal. 

Case  2. — Gustav  P.,  a  weaver,  47  years  old,  had  contracted  syphilis 
twenty-five  years  previously.  For  the  past  four  years  he  had  suffered  from 
attacks  of  vertigo  and  vomiting  which  occurred  without  any  apparent  cause 
and  lasted  for  several  days.  In  the  intervals,  the  patient  was  in  good  health. 
The  pupils  reacted  to  accommodation  but  not  to  light.    The  patellar  reflexes 


228  DISEASES  OF  THE  DIGESTIVE  CANAL 

were  absent,  and  there  was  no  ataxia.  Motility  and  secretion  of  the  stomach 
were  both  normal,  and  the  total  acidity  of  the  gastric  juice  was  64.  The 
administration  of  cerium  oxalate  gave  temporary  improvement. 

Case  3. — Adolphe  L.,  a  servant,  26  years  old,  had  had  syphilis  seven 
years  previously.  For  the  past  six  months  he  had  suffered  from  attacks  of 
vomiting  without  any  apparent  cause.  These  lasted  four  or  five  days,  and 
were  usually  accompanied  by  severe  diarrhoea.  The  left  patellar  reflex  was 
diminished,  and  the  pupils  reacted  to  light.  There  was  no  Romberg  symp- 
tom. The  diagnosis  of  tabes  was  confirmed  in  Professor  Oppenheim's  clinic. 
No  improvement  resulted,  the  attacks  of  gastric  crises  recurring. 

Case  4. — August  W.,  a  mason,  30  years  old,  had  contracted  syphiUs 
ten  years  previously  and  had  had  typical  attacks  of  gastric  crises  with  severe 
pain  for  about  one  year.  As  nothing  but  morphine  would  give  relief,  he 
contracted  the  morphine  habit.  The  attacks  occurred  about  every  month 
during  the  two  and  one  half-years'  observation  of  the  patient. 

5.  Stomach  and   Circulatory  System 

In  valvular  diseases  of  the  heart  and  in  arteriosclerosis, 
gastric  disturbances  occur  which  are  the  result  of  congestion 
in  the  general  circulation,  causing  plethora  abdominalis,  con- 
gestion of  the  liver,  etc. 

Such  patients  complain  most  frequently  of  loss  of  appe- 
tite, and  of  constant  pressure  and  fulness  in  the  epigastrium. 

The  pain  in  angina  pectoris  is  frequently  confused  with 
spasm  of  the  pylorus. 

In  arriving  at  a  diagnosis,  the  existence  of  marked  arterio- 
sclerosis, as  well  as  the  dependence  of  the  attacks  of  pain 
upon  physical  activity,  overloading  the  stomach,  or  the 
advanced  age  of  the  individual,  should  protect  the  examiner 
against  mistaking  the  condition  for  spasm  of  the  pylorus. 
Also,  the  pain  of  angina  pectoris  occurs  behind  the  upper 
portion  of  the  sternum,  and  radiates  generally  to  the  left 
arm;  while  during  the  attack  the  patient  has  a  feeling  of  great 
depression  and  fear  of  impending  death,  which  symptoms 
are  very  characteristic  of  this  disease. 

The  gastric  disturbances  associated  with  disease  of  the 
heart  disappear  as  soon  as  the  circulatory  compensation  has 
been  established.  The  therapy,  therefore,  should  be  suitable  to 
the  primary  lesion  which  is  causing  the  circulatory  disturbance. 


DISEASES  OF  THE  STOMACH  229 

1.  R     Infusi  digitalis,   ^iv  124.0 

Liquoris  potassii  acetatis,   51  Ii'O.O 

Syrupi  aurantii,    ,^v  20.0 

Aquae  destillatse,  q.  s.  ad  5viii       200.0 
M.  Sig. — A  teaspoonful  every  2  or  ."5  liours. 

2.  R     Tincturse  strophanthi, 

Sig. — Five  to  eight  drops  in  a  wineglassful  of  water  t.i.d. 

CLINICAL    CASE 

Dr.  C,  69  years  old,  had  had  no  appetite  for  three  months  and  suffered 
from  a  feehng  of  fuhiess  in  the  epigastrium,  especially  after  eating.  Physical 
examination  showed  advanced  arteriosclerosis,  irregular  action  of  the  heart, 
and  oedema. 

Treatment  consisted  of  rest  in  bed,  and  the  giving  of  a  diuretic  mixture 
and  juniper  tea,  after  which  the  oedema  and  gastric  disturbances  disappeared. 
The  patient  had  come  to  me  for  treatment,  fearing  that  he  was  suffering 
from  carcinoma  of  the  stomach. 

6.    Stomach  and  Diseases  of  the  Lungs 

The  essential  points  concerning  the  relationship  between 
pulmonary  tuberculosis  and  dyspepsia  have  already  been 
considered  in  the  chapter  on  Phthisical  Dyspepsia,  so  it  is 
unnecessary  to  reconsider  this  particular  subject  again. 

The  connection  between  vomiting  and  severe  bronchitis  is 
less  fully  appreciated,  especially  when  such  vomiting  occurs  in 
adults.  Vomiting  is  regularly  present  in  children  with  whoop- 
ing-cough. Adults,  however,  suffering  from  bronchitis,  often 
consult  the  physician  for  relief  from  the  vomiting, — instead  of 
from  the  bronchitis  which  is  the  cause  of  such  vomiting. 

In  these  cases,  the  vomiting  usually  follows  a  severe 
attack  of  coughing  early  in  the  morning,  shortly  after  break- 
fast. If  the  physician  is  able  to  determine,  from  the  state- 
ments of  the  patient,  the  dependence  of  the  vomiting-attack 
upon  the  bronchitis,  both  the  diagnosis  and  the  therapy  of 
this  form  will  easily  be  established. 

Either  Ems  or  Salzbrunner  salts  should  be  given  in  hot 
milk;    and  codeine  or  morphine,  in  the  usual  way. 

The  following  clinical  cases  will  illustrate  the  connection 
between  attacks  of  vomiting  and  bronchitis: 


230  DISEASES  OF  THE  DIGESTIVE  CANAL 

CLINICAL    CASES 

Case  J. — Margaret  H.,  28  years  old,  the  wife  of  a  merchant,  had  for 
four  months  suffered  from  vomiting  of  a  green-colored  mucus  with  a  bitter 
taste,  which  occurred  early  in  the  morning  soon  after  rising.  By  a  very 
carefully  obtained  anamnesis,  it  was  established  that  the  patient  had  first 
suffered  from  a  spasmodic  cough,  which  soon  produced  nausea  and  vomiting. 
After  meals,  the  patient  experienced  no  discomfort,  and  the  bowels  were 
regular.  The  total  acidity  of  the  test-breakfast  was  44.  The  examination 
of  the  vomitus  proved  it  to  consist  of  sputum.  Improvement  followed 
treatment  with  Ems  salts  and  codeine. 

Case  2. — Franz  K.,  a  locksmith,  46  years  old,  had  had  no  appetite 
for  three  weeks.  Every  morning  after  breakfast  the  patient  had  an  attack 
of  coughing,  which  was  almost  invariably  followed  by  vomiting,  but  during 
the  rest  of  the  day  he  had  no  stomach-trouble.  The  bowels  were  regular, 
and  the  motor  and  secretory  functions  of  the  stomach  were  normal,  the 
total  acidity  being  50.  Rales  were  present  in  both  lungs.  The  patient 
entirely  recovered  under  an  anti-bronchitis  treatment. 

7.    Stomach  and  Qenito=Urinary  System 

Apart  from  nephritic  colic,  which  may  be  confused  with 
spasmodic  conditions  of  the  stomach,  and  chronic  nephritis, — 
which  sometimes  leads  to  passive  congestion,  pressure  in  the 
stomach,  and  finall}'  to.  urinic  phenomena, — the  diseases  of 
the  prostate  require  special  consideration. 

As  the  result  of  inflammatory  conditions  of  this  gland, 
distention  of  the  bladder  and  a  feeling  of  fulness  in  the  abdo- 
men occur.  Such  patients  usually  seek  the  advice  of  the 
phj'sician  on  account  of  the  gastric  pressure. 

The   following  clinical   cases   may  serve  to   illustrate: 

CLINICAL    CASES 

Case  1. — Herman  S.,  a  capitalist,  61  years  old,  had  for  about  six 
months  suffered  from  loss  of  appetite,  occasional  vomiting,  and  from  pressure 
and  a  feeling  of  fulness  in  the  epigastrium,  as  well  as  bladder  trouble, — 
dribbling  of  urine,  etc.  The  total  acidity  of  the  test-breakfast  was  50,  and 
the  motor  powers  of  the  stomach  were  normal.  The  physical  examination 
revealed  a  tumor  about  the  size  of  the  head,  which  was  found  just  above 
the  symphysis, — midway  between  the  umbiUcus  and  the  symphysis, — and 
which  proved  to  be  a  distended  bladder.  Catheterization  caused  a  dis- 
appearance of  the  "stomach-troubles." 


DISEASES  OF  THE  STOMACH  231 

Case  2. — Rudolph  H.,  a  tailor  32  years  old,  had  been  without  appetite 
for  three  weeks,  and  had  a  feeling  of  fulness  in  the  entire  epigastrium.  The 
bowels  were  regular,  but  the  patient  was  occasionally  nauseated  and  ex- 
perienced some  trouble  in  urination.  He  remembered  having  taken  a  severe 
cold  prior  to  his  illness.  A  tumor  above  the  symphysis  proved  upon  exam- 
ination to  be  a  distended  urinary  bladder. 

Treatment  consisted  of  belladonna  suppositories,  sitz-baths,  and  a 
diuretic;  after  which  the  micturition  became  normal,  and  dyspeptic 
symptoms  ceased, 

8.  Stomach  and  Liver,  Pancreas  and  Spleen  [Gall= Bladder] 

Enlargement  of  the  liver,  -from  inflammatory  processes 
and  from  stasis  in  the  portal  circulation,  often  manifests 
itself  subjectively  by  a  constant  feeling  of  fulness  in  the  epi- 
gastrium, caused  by  the  consequent  crowding  upon  the 
abdominal  space, — especially  when  there  is  a  simultaneously 
existing  ascites. 

The  same  subjective  symptoms  are  produced  by  enlarge- 
ment of  the  spleen. 

It  has  already  been  repeatedly  mentioned  that  gall- 
stone colic  may  often  be  confused  with  spasmodic  pain  of  the 
stomach.  The  sporadic  occurrence  of  gall-stone  colic,  and 
also  the  enlargement  and  sensitiveness  of  the  liver  and  gall- 
bladder in  acute  cases,  should  readily  protect  the  physician 
from  making  a  wrong  diagnosis. 

[The  advances  made  in  early  diagnosis  and  treatment  of 
diseases  of  the  biliary  passages, — due  largely  to  American 
and  English  surgery, — deserve  a  fuller  consideration  of  the 
subject  than  the  author  has  given. 

The  early  symptoms  of  gall-bladder  disease  are  very 
often  of  a. dyspeptic  nature.  Such  patients  have  been  treated 
for  weeks,  months  and  years  for  stomach-trouble;  and  only 
the  development  of  active  and  positive  signs  of  gall-bladder 
disease  has  caused  the  correct  diagnosis  to  be  made  in  many 
of  these  cases. 

Thanks  largely  to  the  opportunities  which  surgery  has 
offered  of  making  comparisons  between  the  clinical  symptoms 
and  the  pathology  of  the  earlier  inflammatory  affections  of 


23^2  DISEASES  OF  THE  DIGESTIVE  CANAL 

the  biliary  tract,  the  clinician  is  now  able  to  recognize  such 
by  the  subjective  and  objective  symptoms  of  the  patient. 
But  cases  are  still  too  frequent  where,  owing  to  complica- 
tions,— such  as  adhesions,  etc., — the  symptoms  are  so  indefinite 
and  the  symptomatology  so  confusing  that  the  differential 
diagnosis  of  organic  gastric  disease  is  difficult  and  perplexing. 

In  the  differential  diagnosis  between  organic  stomach- 
affections  and  diseases  of  other  organs  of  the  abdomen,  includ- 
ing the  gall-bladder,  the  cardinal  point  is  that  the  symptoms 
of  organic  stomach-diseases  are  dependent  upon  food  and  that 
the  symptoms  of  organic  diseases  of  other  organs  of  the 
abdomen  are  not. 

In  peptic  ulcer,  for  example,  the  pain  which  occurs  from 
one  to  four  hours  after  eating  is  the  most  characteristic  symp- 
tom of  that  disease, — all  other  symptoms,  such  as  vomiting, 
hyperacidit}'',  gas,  and  even  hemorrhage,  being  present  in 
diseases  of  other  organs  of  the  abdomen;  but  the  pain  phe- 
nomenon of  ulcer  differs  from  the  pain  caused  b}^  disease  of 
other  organs,  in  that,  although  sometimes  temporarily  eased 
by  foods,  warm  drinks,  soda,  etc.,  it  recurs  regularly  after 
eating,  usually  two  to  four  hours,  throughout  the  ulcer-period. 

In  contrast  to  this,  the  pain  in  gall-stone  disease  is  inde- 
pendent of  eating,  is  not  modified  by  food,  is  irregular  in 
relation  to  meals,  and  is  periodical  in  occurrence;  like  the  pain 
of  ulcer,  it  is  located  in  the  epigastrium,  but  it  has  a  wider 
field  of  radiation,  usually  extending  to  the  right  costal  arch 
and  scapular  region,  and  is  generally  of  a  more  sudden  onset. 

In  cystic  duct-obstruction  and  in  cholecystitis,  pain  is 
occasionally  more  or  less  constant  in  the  epigastrium,  and  is 
for  this  reason  more  likely  to  be  confused  with  gastric  pain 
than  is  the  pain  of  cholelithiasis.  But  here  again,  the  pain  is 
independent  of  and  not  modified  by  the  kind  and  amount  of  food 
eaten,  which  fact  excludes  the  pain  as  being  of  gastric  origin. 

Tenderness  to  pressure  in  the  epigastrium  may  be  either 
present  or  absent  in  cholelithiasis,  but  in  cholecystitis  it  is 
a  more  constant  physical  sign.  It  is  located  usually  more  to 
the  right  of  the  median  line  in  the  region  of  the  gall-bladder 


DISEASES  OF  THE  STOMACH  233 

than  otherwise.  There  is  quite  frequently  a  tenderness  to 
pressure  at  the  right  of  the  ninth  to  the  twelfth  dorsal  verte- 
brae in  both  gall-bladder  and  liver  disease,  and  heavy  per- 
cussion over  the  posterior  hepatic  area  is  more  painful  than 
over  the  corresponding  area  of  the  left  dorsum. 

In  gastric  ulcer,  the  point  of  tenderness  is  sharply  defined, 
and  is  almost  always  minutely  localized  by  the  patient  to  a 
small  area  throughout  the  ulcer-period.  In  a  considerable 
number  of  ulcer-patients,  the  area  lying  to  the  left  of  the  ninth 
to  the  twelfth  dorsal  vertebrse  is  sensitive  to  pressure. 

Vomiting  is  common  to  both  cholelithiasis  and  peptic  ulcer, 
although  not  so  frequently  a  significant  factor  in  the  former. 

In  gall-stone  disease,  vomiting  appears  soon  after  the 
initial  pain  and  may  give  some  relief.  It  is  profuse  only  when 
the  attack  comes  on  after  a  meal,  and  then  the  normal  food 
and  the  normal  acidity  of  the  vomitus  will  be  recognized. 

In  gastric  ulcer,  vomiting  occurs  from  one  to  four  hours 
after  meals,  at  a  time  when  the  pain  and  hyperacidity  are 
most  intense,  and  it  is  usually  followed  by  relief  from  pain. 

In  uncomplicated  gall-stone  disease,  the  gastric  contents 
will  be  found  normal. 

In  organic  stomach-disease,  the  gastric  analysis  will 
show  characteristic  variations  from  the  normal,  depending 
upon  the  nature  of  the  disease, — as  in  ulcer,  dilatation,  car- 
cinoma, etc. 

In  chronic  disease  of  the  gall-bladder,  adhesions  so 
frequently  exist  between  the  gall-bladder  and  the  pylorus 
and  other  structures,  and  so  disturb  their  functions,  that  a 
differential  diagnosis  is  possible  only  when  an  intelligent 
early  history  is  obtainable.* 

Graham  says  that  in  the  study  of  these  cases,  ''there  is 
nothing  so  important  as  the  carefully  developed  history,  and 
that  when  this  can  be  clearly  obtained,  errors  in  diagnosis  will 
be  at  a  minimum." 

[  *  For  helpful  suggestions  in  this  editorial,  I  owe  my  thanks  to  Dr.  Chris- 
topher Graham,  of  the  Rochester  Clinic,  who,  in  a  recent  letter,  discussed  the 
general  diagnostic  principles  of  early  gall-bladder  disease.] 


234  DISEASES  OF  THE  DIGESTIVE  CANAL 

He  considers  the  most  important  differential  points  of 
gall-bladder  dyspepsia  to  be:  ''Little  stress  laid  on  food  as  a 
cause  of  pain;  the  irregularity  of  symptoms,  as  to  time  of 
attack;  the  period  over  which  the  attack  runs;  the  dis- 
comforts and  pain  depending  little,  if  any,  upon  the  amount 
or  kind  of  food;    and  the  distress  being  epigastric."] 

A  few  suggestions  concerning  the  therapy  of  chole- 
lithiasis will  be  parenthetically  offered. 

In  the  acute  attack,  the  physician  should  prescribe  strict  rest  in  bed, 
and  the  application  of  hot  linseed  poultices  and  one  or  two  leeches  in  the 
region  of  the  gall-bladder,  with  the  internal  administration  of  0.03  [{  gr.] 
extract  of  belladonna,  or  0.001  [^^j  gr.]  of  eumydrin,  three  to  four  times 
daily.  In  case  there  is  a  tendency  to  vomiting,  either  morphine  may  be 
given  subcutaneously,  or  the  above-mentioned  remedies  may  be  given  in 
suppositories  per  rectum. 

The  nourishment  should  be  limited  to  tea,  milk,  and  cereal  soups. 

Chronic  cholelithiasis,  as  well  as  the  after-treatment  of  an  acute  attack, 
should  receive  attention  preferably  at  Carlsbad,  where  the  hot  mud-poultices 
may  be  used  to  great  advantage.  The  Carlsbad  water  should  be  drunk  as 
hot  as  possible,  in  amounts  of  three  or  four  glasses  daily, — three  in  the  morn- 
ing and  one  in  the  afternoon, — for  a  period  of  about  four  weeks. 

For  very  stubborn  and  severe  cases,  the  physician  should  prescribe 
rest  in  bed  and  the  use  of  the  hot  poultices  from  four  to  six  weeks,  befoi'e 
advising  operative  measures. 

If  the  Carlsbad  regime  proves  ineffective,  the  oil-treatment  should  he 
prescribed.  A  wineglassful  of  olive  or  almond  oil  sliould  be  drunk  every 
morning  for  about  four  weeks.  Recently  chologen*  has  proved  useful  in 
individual  cases.    It  should  be  given  for  a  period  of  from  six  to  ten  weeks. 

Eunatrol,  salicylic  acid,  and  i^robilin  pills, — which  consist  of  sal- 
icylic acid,  sodium  oleate,  phenolphthalein  and  menthol, — should  be  taken 
before  breakfast  and  in  the  evening,  in  doses  of  three  or  four  pills,  with 
one-third  to  one-half  litre  of  hot  water. 

The  patient  should  be  referred  to  a  surgeon  when  internal  therapy 
fails,  or  when  attacks  of  cholelithiasis  are  frequent.  [The  medical  treat- 
ment of  gall-stone  disease  is  A-ery  uncertain  in  its  results  and  owing  to  the 
pathological  conditions  present  it  can  scarcely  be  more  than  palliative. 
Early  sm-gical  treatment  should  therefore  be  advised  unless  contraindications 
to  an  operation  exist.] 

*  There  are  three  strengths, — No.  1  for  Kght,  No.  2  tor  medium  severe, 
and  No.  3  for  severe  cases.  The  physician  should  prescribe  two  tablets  before 
the  dinner  the  first  day,  and  two  tablets  before  luncli  and  dinner  on  the  second 
day,  and  on  the  third  day  two  tablets  before  each  meal;  while  on  the  fourth  day, 
the  patient  should  begin  over  again,  etc. 


DISEASES  OF  THE  STOMACH  235 

Neoplasms  of  the  pancreas, — such  as  cysts,  carcinomata, 
etc.,  as  well  as  other  disorders  of  the  pancreas, — such  as 
concretions  and  hemorrhages, — are  frequently  confused  with 
gastric  diseases. 

A  carcinoma  of  the  pancreas,  which  causes  stagnation  of 
the  contents  of  the  stomach  by  compressing  the  stomach- 
outlet,  cannot  be  differentiated  in  some  cases  from  a  cancer 
of  the  pylorus. 

In  suspected  cases  of  pancreatic  disease,  the  physician 
must  never  neglect  to  examine  the  urine  carefully  for  sugar, 
and  also  the  stools  for  an  increased  fat-content. 

Fortunately,  so  far  as  therapy  is  concerned,  a  differenti- 
ation between  the  two  affections  is  unimportant. 

9.  Stomach  and  Intestinal  Diseases 

Numerous  sufferers  from  intestinal  diseases  believe  their 
real  trouble  is  of  gastric  origin.  Especially  is  this  the  case 
with  those  who  have  the  so-called  "intestinal  dyspepsia." 

By  the  term  "intestinal  dyspepsia"  is  understood  the 
occurrence  of  all  kinds  of  dyspeptic  symptoms,  such  as  pres- 
sure, fulness  in  the  epigastrium,  loss  of  appetite,  nausea,  and 
even  vomiting,  flatulence,  distention,  and  a  more  or  less 
severe  intestinal  catarrh, — the  functions  of  the  stomach  mean- 
while being  normal.  In  'addition  to  the  above  symptom, 
griping  pains  occur  in  those  cases  where  an  organic 
intestinal  affection  exists. 

Since  such  complaints  have  their  origin  mostly  in  the  colon, 
which  runs  transversely  through  the  epigastrium,  its  close  inti- 
macy with  the  stomach  may  very  easily  confuse  both  the  patient 
and  the  physician  as  to  the  exact  nature  of  the  affection. 

Disturbances  of  the  functions  of  the 
intestine  are  always  objectively  evident. 
Either  persistent  constipation  or  diarrhoea,  or  alternating 
constipation  and  diarrhoea,  will  be  found  present. 

With  these  symptoms,  cramp-like  pains,  which  are  a  sign 
of  spasm  of  the  intestine,  very  frequently  occur.  Occasionally, 
the  movements  of  the  bowels  are  normal,  the  patient  suffering 
only  from  impaired  absorption  and  gaseous  disturbances. 


236  DISEASES  OF  THE  DIGESTIVE  CANAE 

Improvement  naturally  results  in  these  cases  only  through 
treatment  of  the  intestine. 

It  is  often  very  difficult  to  determine  the  location  and 
intensity  of  a  catarrhal  condition  of  the  intestine.  If  consti- 
pation exists,  it  is  almost  always  of  a  spastic  nature,  reciuiring 
the  use  of  belladonna, — 0.01  (J  gr.)  of  the  extract,  or  10  drops 
of  the  tincture, — three  times  daih',  also  a  non-irritating  diet 
and  Vich}'  water. 

If  diarrha?a  is  present,  with  only  occasional  constipation, 
the  patient  should  be  given  a  non-irritating  diet,  cond:)ined 
with  intestinal  astringents,  such  as  tannocol,  bismuth,  etc. 

Fuller  details  will  be  given  in  the  section  on  Chronic 
Intestinal   Catarrh. 

CLINICAL    CASES 

Case  1. — Otto  G.,  a  business  man  42  years  old,  had  for  fifteen  years 
suffered  from  attacks  of  -v'ertigo  after  errors  in  diet.  He  had  also  been 
troubled  with  heartburn  and  a  feeling  of  fulness  in  the  epigastrium  and  in 
the  entire  abdomen.  There  had  been  much  flatulence,  and  the  stools 
were  lumpy  and  of  a  spongy  consistency.  He  had  occasional  diarrhcea, 
and  had  lost  26  pounds  in  weight.  There  was  no  hyperchlorhydria.  The 
liver  and  spleen  were  enlarged.  Treatment  consisted  of  a  bland,  non- 
irritating  diet,  the  use  of  Vichy  water  and  the  calcium  salts,  with  subni- 
trate  of  bismuth, — after  which  the  stools  became  regular,  and  the  flatulence 
and  dyspeptic  sjonptoms  disappeared.  He  gained  10  pounds  in  weight, 
but  noticed  that  he  still  suffered  from  vertigo  whenever  he  ate  eggs. 

Case  2. — Miss  L.,  a  singer  26  years  old,  had  been  constipated  twelve 
years,  so  that  purgatives  were  necessary.  For  six  months  she  had  suffered 
from  languidness  half  an  hour  after  dinner,  and  nausea  in  the  morning, 
followed  by  vomiting  of  mucus  and  bile.  The  appetite  was  poor,  and  the 
patient  slept  badly. 

Physical  examination  was  negative.  The  patient  was  given  a  coarse 
constipation-diet,  after  which  the  bowels  became  immediately  regular,  and 
in  three  weeks  all  the  dyspeptic  symj^toms  had  disappeared. 

10.   Stomach  and  Sexual  Organs 

The  co-relation  between  the  female  sexual  organs  and  the 
stomach  is  generally  recognized,  especially  the  vomiting  asso- 
ciated with  uterine  colic  before  or  during  the  menses,  and  also  the 
vomiting  caused  by  retroflexion  of  the  uterus,  and  by  pregnancy. 


DISEASES  OF  THE  INTESTINE  237 

It  is  therefore  essential,  before  making  a  diagnosis  of 
nervous  vomiting,  to  examine  the  pelvis  carefully,  in  order  to 
determine  the  condition  of  the  uterus,  since  the  statements 
given  in  the  anamnesis  of  these  cases  are  so  often  unreliable 
and  misleading. 

Chronic  metritis,  perimetritis,  ovarian  disease,  prolapsus 
of  the  uterus,  etc.,  are  extremely  often  the  cause  of  nervous 
dyspepsia,  nervous  eructation,  etc. 

In  regard  to  the  male  sexual  organs,  it  may  be  mentioned 
that  diseases  of  the  semen-producing  organs  are  closely  related 
to  disorders  of  digestion.  The  dyspepsia  caused  by  sexual 
neurasthenia  following  masturbation,  prostatorrhoea,  sper- 
matorrhoea, or  phosphaturia,  has  already  been  spoken  of  in 
sufficient  detail  in  the  chapter  on  Nervous  Dyspepsia. 

Diseases  of  the  Intestine 

Introduction. — Diseases  of  the  intestinal  tract  are  even 
more  extensive  and  common  than  those  of  the  stomach.  An 
enormous  number  of  people  suffer  from  irregularity  of  the 
bowels, — diarrhoea,  constipation,  or  flatulence;  so  prevalent 
are  these,  indeed,  that  in  civilized  man,  particularly  in 
adults,    a  normally  functioning  intestine  is  rarely  found. 

The  causes  of  these  prevalent  disturbances  of  the  bowels 
are  the  use  of  artificial  "foods"  during  the  first  few  years  of 
childhood;  and  in  adult  hfe,  unhygienic  living, — such  as 
sedentary  occupations,  insufficient  exercise,  mental  over-work, 
frequent  overloading  of  the  digestive  tract,  irregular  meals, 
alcoholic  excesses,  etc. 

The  great  length  of  the  intestinal  canal,  amounting  on 
an  average  to  from  7  to  8  metres,  frequently  makes  the  diag- 
nosis of  the  exact  location  and  character  of  any  special  disease 
very  difficult.  Our  present  knowledge  of  the  individual  dis- 
eases of  the  intestine  is  much  less  advanced  and  accurate  than 
our  knowledge  of  the  stomach,  because  it  is  much  more  diffi- 
cult to  examine  the  functions  of  the  intestine  than  those  of 
the  stomach,  by  means  of  a  so-called  test-meal.     Only  very 


338  DISEASES  OF  THE  DIGESTIVE  CANAL 

recently,  following  the  initiative  of  Schmidt  and  Strasburgcr, 
clinicians  have  begun  to  use  the  test-meal,  subjecting  the  stool 
formed  from  it  to  a  chemical  and  microscopical  examination. 

Unfortunately,  this  method  of  examination  can  be 
utilized  only  in  the  clinic  and  in  hospital  practice,  being  scarcely 
adaptable  to  the  every-day  use  of  the  general  practitioner. 
To  be  carefully  performed,  it  requires  a  trained  nurse  and 
considerable  routine  on  the  part  of  the  physician;  and  in 
consideration  of  these  factors,  is  better  left  to  the  use  of 
the  specialist. 

In  this  book,  we  cannot  go  into  the  anatomical  and 
physiological  details  of  the  intestinal  tract,  especially  since  it 
is  taken  for  granted  that  such  knowdedge  is  already  famihar 
to  the  physician. 

A  few  remarks  concerning  the  characteristics  of  a  normal 
stool  only  will  be  made.  From  a  person  on  a  mixed  diet, 
it  is  always  of  large  caliber  and  semi-solid  consistency.  Clumps 
of  yellowish-brown  mucus,  but  never  membranous  mucus, 
may  be  adherent  to  its  superficial  surface.  The  normal  color 
may  be  any  of  the  shades  from  light  yellow  to  dark  brown; 
it  is  black-brown  only  after  certain  foods, — such  as  red  wine, 
blueberries,  spinach,  etc. 

In  twenty-four  hours  the  stool  will  amount  to  about 
170  grams. 

With  vegetarians  and  those  who  have  temporarily  eaten 
largely  of  fruit  and  vegetables,  it  may  be  normally  unformed 
and  of  pulpy  consistency. 

After  the  eating  of  much  milk  and  butter,  the  color  may 
be  a  decided  light  yellow  without  being  pathological. 

Every  stool  that  differs  from  the  above-indicated  normal 
stool  is  pathological,  as  we  shall  see  below  in  describing  stools 
of  hard  consistency  and  those  of  small  calibre,  or  of  unformed, 
semi-liquid,  or  fluid  consistency,  etc. 

Etiology. — In  general,  the  causes  of  disease  of  the  intes- 
tine are  the  following: 

1.  Diseases  of  the  Stomach. — Impairment  of  gastric  diges- 
tion is  frequently  the  cause  of  disturbances  of  the  intestine. 


DISEASES  OF  THE  INTESTINE  239 

Chronic  gastritis,  especially,  gives  rise  to  a  secondary  chronic 
intestinal  catarrh,  although  it  should  be  mentioned  that  both 
diseases  are  often  caused  by  the  same  etiological  factor,  such 
as  excess  in  eating  or  drinking. 

The  secretion  of  too  much  as  well  as  of  too  little  gastric 
juice  will  disturb  the  intestinal  digestion.  If  a  hyperacid 
gastric  juice  enters  the  duodenum,  the  bile  and  the  pancreatic 
juice  are  unable  to  normally  neutrahze  the  acid  chyme  after 
it  has  entered  the  bowel. 

On  the  other  hand,  when  chyme  which  is  deficient  in 
acids  enters  the  duodenum,  there  is  insufficient  stimulation 
for  the  secretion  of  bile  and  pancreatic  juice  of  a  normal 
quality  and  quantity. 

In  both  of  the  above  instances,  intestinal  digestion 
suffers;  and  catarrh  of  the  smaller,  and  later  of  the  larger, 
intestine  results.  Diarrhoea  first  sets  in  after  some  error  in 
diet;   and  after  existing  for  several  years,  it  becomes  chronic. 

In  simple  gastric  dyspepsia,  when  the  appetite  is  much 
reduced  and  when  even  hght,  easily  assimilated  foods  cause 
disturbances  in  peptic  digestion,  the  functions  of  the  intestine 
become  implicated,  because  normal  peristalsis  cannot  be 
maintained  with  a  deficient  amount  of  nourishment.  It  is 
in  this  way  that  chronic  constipation  most  commonly  develops. 

An  organic  disease  of  the  stomach  will  disturb  the  func- 
tions of  neighboring  organs,  such  as  the  transverse  colon,  and 
especially  the  duodenum.  For  example,  hyperacidity  of  the 
gastric  juice  may  cause  the  development  of  a  peptic  ulcer  in 
the  duodenum,  or  adhesions  may  form  between  the  stomach 
and  the  transverse  colon  from  perigastritis,  giving  rise  to  the 
formation  of  fistulse,  and  thereby  to  severe  disturbances  in 
the  functions  of  the  intestine. 

The  converse  may  occur;  that  is,  primary  intestinal 
disease,  especially  catarrh  of  the  bowels,  may  cause  second- 
ary disturbances  of  the  stomach,  as  we  have  seen  in  the  chapter 
on  Nervous  Dyspepsia. 

2.  Frequent  Indigestion. — This  is,  especially  in  children, 
one   of  the   most   common   causes   of   chronic   disease   of  the 


240  DISEASES  OF  THE  DIGESTIVE  CANAL 

intestine,  for  the  reason  that  insufficient  care  is  maintained 
to  produce  an  anatomical  cure  following  acute  conditions. 
Such  cases  are  usualh'  considered  cured,  if  the  violent  symj)- 
toms  have  ceased,  or  if  the  pain  and  tliarrha^a,  with  the  help 
of  an  anti-diarrha?a  remedy,  such  as  opium,  have  disap- 
peared; then  the  patient  is  not  observed  long  enough,  nor  a 
sparing  diet  adhered  to  for  a  sufficient  time,  to  allow  the 
intestine  to  be  restored  to  its  normal  anatomical  condition. 
Opium  is  given  entirely  too  often  in  sueh  cases.  In 
diseases  of  the  intestine,  it  would  be  better  if  it  were  entirely 
dispensed  with.  Evcr}^  case  of  acute  diarrhoea  requires  the 
most  careful  treatment  in  order  to  prevent  permanent  ana- 
tomical alterations  of  the  mucous  membrane  of  the  intestine. 

Inherited  tendencies  toward  alimentary  troubles  are  recognized,  and 
there  are  undoubtedly  families  in  which  an  alteration  in  the  functions  of 
the  intestine  is  a  prevalent  trait.  Several  members  of  one  family  will  have 
a  tendency  toward  diarrhoea;  while  in  another  family,  a  corresponding 
inclination  exists  toward  constipation. 

3.  Infections  and  Intoxications. — Both  acute  and  chronic 
affections  frequently  cause  acute  and  chronic  disturbances  of 
the  intestine.  I  need  mention  only  lead,  copper,  arsenic, 
phosphorus,  opium,  and  ptomaine  poisoning,— besides  dysen- 
tery, diphtheritic  and  syphilitic  infections, — which  may  be 
associated  with  an  inflammatory  condition  or  ulceration  of 
the  intestine. 

4.  The  General  Constitution. — The  general  constitution  has 
the  greatest  influence  on  the  occurrence  of  functional  intestinal 
diseases, — especially  of  hereditary  constipation.  Persons  with 
the  habitus  enteropticus, — especially  women  after  pregnancy 
who  have  relaxation  of  the  abdominal  walls,  and  in  addition 
to  the  congenital,  have  acquired  enteroptosis, — are  predis- 
posed to  atonic  constipation,  the  existence  of  which  for  several 
years  will  give  rise  to  a  large  number  of  disturbances  and  will 
finally  lead  to  an  organic  disease  of  the  intestine,  as  we  shall 
see  further  on. 

5.  Neighboring  Organs. —  Hemorrhoids  may  be  either  the 
result  or  the  cause  of  chronic  constipation. 


DISEASES  OF  THE  INTESTINE  241 

Diseases  of  the  neighboring  organs,  such  as  the  peri- 
toneum, liver,  spleen,  kidneys,  or  heart,  are  also  detrimental 
to  the  normal  functions  of  the  intestine. 

Passive  congestion  in  either  the  greater,  the  lesser  or  the 
portal  circulation  causes  stasis  of  the  blood  in  the  mesenteric 
veins,  producing  a  passive  congestion  of  the  blood-vessels  of 
the  intestinal  mucous  membrane,  with  its  clinical  result. 

The  bands  formed  from  peritonitis,  and  further  acute 
and  chronic  peritonitis,  may  give  rise  to  the  most  severe 
intestinal  disturbance. 

6.  Nervous  System. — Besides  the  above-mentioned  etio- 
logical factors,  there  are  a  large  number  of  purely  nervous 
affections  of  the  intestine,  the  exact  nature  of  which  we  do 
not  understand. 

It  is  of  the  utmost  importance  that  the  physician  seek 
and  remove  the  causa  morbi,  so  as  to  produce  a  permanent 
cure  in  every  case  of  acute  and  chronic  intestinal  disease. 

Symptomatology. — The  symptomatology  in  intestinal 
diseases,  just  as  in  affections  of  the  stomach,  is  divided  into 
subjective     and     objective. 

The  subjective  symptoms  consist  of  pressure,  feel- 
ing of  fulness,  distention  not  merely  in  the  epigastrium  but  in 
the  entire  abdomen,  flatulence,  nausea,  the  tendency  to  vomit, 
and  vomiting;  also  cutting,  gnawing,  cramp-like,  recurrent  pain 
in  the  region  of  the  umbilicus  and  radiating  to  all  sides,  the  so- 
called  ''mesogastralgia, "  which  may  increase  to  the  sensation 
of  oppressive  constriction  and  finally  to  severe  colic. 

Besides  the  above,  constipation  and  diarrhoea  occur  as 
two  subjective  symptoms  which  merge  into  the  objective. 

The  objective  signs  and  symptoms  in  disease  of 
the  intestine  must,  as  a  rule,  be  obtained  from  the  statements 
of  patients  alone,  since  such  cases  are  usually  ambulatory  and 
not  under  the  constant  observation  of  the  physician. 

The  most  common  symptoms  are  irregularity  in  the 
evacuation  of  the  bowels,  constipation,  diarrhoea,  and  fever; 
besides  meteorism  and  the  escape  of  flatus,  mucus,  blood,  pus, 
concretions,  substances  resembling  gravel,  foreign  bodies,  etc. 

16 


242  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  significance  of  the  individual  subjective  and  objec- 
tive symptoms  will  not  be  discussed  until  later  on. 

Examination  of  the  Patient. — The  examination  of  a 
patient  suffering  from  intestinal  trouble  should  consist  in  the 
following: 

1.  Anamnesis. 

2.  Ph3''sical  Examination. 

3.  Chemical  and  Microscopical  Examination  of  the  Stools, 

and  if  necessary  of  the  Stomach-Contents. 

1.  In  obtaining  the  anamnesis,  the  physician  should 
proceed  exactly  as  in  Diseases  of  the  Stomach,  to  which 
chapter  the  reader  is  referred,  in  order  to  avoid  repetition. 

The  differential  diagnostic  points,  however,  may  properly 
be  given  here: 

Pressure,  fulness  and  distention  throughout  the  entire 
abdomen,  which  are  independent  of  eating  l^ut  which  are, 
on  the  other  hand,  dependent  upon  the  evacuation  of  the 
bowels,  are  indicative  of  an  intestinal  affection,  especially 
when  they  occur  early  in  the  morning  before  food  has  been 
eaten,  or  when  the  symptoms  are  associated  with  irregularity 
of  the  bowels.  If,  on  the  other  hand,  these  symptoms 
occur  only  after  eating,  and  are  limited  to  the  epigastrium, 
the  physician  should  suspect  that  their  origin  is  in  the  stomach. 
While  in  the  stomach,  pressure  is  alleviated  by  eructations; 
in  the  intestine,  it  is  relieved  by  the  escape  of  gas. 

In  chronic  affections  of  the  intestine,  actual  pain  is  rarely 
associated  with  eating;  while  in  disease  of  the  stomach, 
pain  is  directly  dependent  upon  the  quality  and  quantity  of 
food, — as  has  been  shown  in  the  chapter  on  Gastric  Ulcer. 

Intestinal  pain,  as  a  rule,  lasts  for  only  a  few  minutes, — 
very  rarely  for  hours,  except  in  such  cases  as  lead  colic, — 
and  it  is  usually  relieved  by  the  escape  of  gas. 

The  mistaking  of  spasm  of  the  pylorus  for  intestinal 
colic  is  notably  frequent  in  diagnosis.  The  point  just  men- 
tioned,— that  in  intestinal  colic  the  pain  is  of  only  temporary 
occurrence, — will  guard   against  such  an  error,   especially  if 


DISEASES  OF  THE  INTESTINE  243 

the  physician  bears  in  mind  that  the  pain  of  pyloric  spasm 
occurs  regularly  at  certain  times  after  meals. 

If  the  physician  determines  from  the  anamnesis  that  the 
patient  is  suffering  from  an  irregularity  of  the  bowels,  he  will 
have  much  less  difficulty  in  differentiating  whether  stomach 
trouble  or  disease  of  the  intestine  is  present. 

I  would  not  mention  this  matter  in  so  much  detail,  had  I  not  so  fre- 
quently seen  conditions,  which  were  in  reality  intestinal  colic,  diagnosed  as  a 
spasmodic  affection  of  the  stomach.  And  again,  when  the  physical  exam- 
ination has  determined  that  the  patient  has  a  congenital  or  an  acquired 
enteroptdsis,  the  diagnosis  of  dilatation  of  the  stomach,  secondary  to  spasm 
of  the  pylorus,  was  assumed.  Accurate  observation,  however,  would  soon 
reveal  the  fact  that  the  alleged  pylorospasm  was  in  reality  intestinal  colic 
resulting  from  spastic  constipation,  and  that  the  alleged  dilatation  of  the 
stomach  was  nothing  more  nor  less  than  gastroptosis. 

2.  Physical  Examination. — The  technic  of  palpation  has 
already  been  considered  in  the  Introduction  to  Diseases  of 
the  Stomach.  The  following,  however,  must  be  particularly 
mentioned  in  this  place  as  requiring  the  close  observation  of 
the  physician: 

The  hahitus,  the  degree  of  nutrition  of  the  patient,  his 
color,  the  condition  of  the  abdominal  wall,  and  whether  dias- 
tasis of  the  recti  muscles  is  present,  as  well  as  visible  peri- 
stalsis of  the  coils  of  the  small  intestine. 

An  attempt  should  be  made  to  palpate  the  colon  from  the 
C2ecum  to  the  sigmoid  flexure.  This  is  best  done  by  a  rolling 
movement  with  the  palmar  surfaces  of  the  extended  fingers 
placed  at  right  angles  to  the  course  of  each  portion  of  the  colon. 
It  is  also  frequently  possible  to  palpate  the  appendix. 

When  the  abdominal  walls  are  thick  and  rigid,  the  colon 
is  not  palpable;  but,  on  the  contrary,  it  can  almost  alwaj^s  be 
felt  when  the  abdominal  walls  are  relaxed,  especially  in 
women  who  have  given  birth  to  several  children,  or  in  men 
who  were  formerly  stout  and  have  become  emaciated.  It  is 
especially  easy  to  palpate  the  transverse  colon  when  it  is 
contracted  and  hard;  while  it  is  almost  impossible  to  differ- 
entiate a  soft,  empty  colon  from  the  neighboring  structures. 


244  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  palpation  of  the  colon  cannot  be  theoretically  learned, 
but  requires  considerable  practice  and  experience.  Beginners 
should  select,  for  examination,  individuals  who  are  emaciated 
or  those  who  have  relaxed  abdominal  walls. 

Particular  attention  should  be  given  to  the  investigation 
of  areas  of  the  colon  that  are  sensitive  to  pressure.  Some- 
times the  entire  organ  is  sensitive,  especially  in  a  catarrhal 
condition  associated   with  spasmodic   contraction. 

The  abdomen  should  be  carefully  palpated,  also,  for 
possibly  existing  tumors.  The  inexperienced  may  easily 
mistake  fecal  accumulations  or  Irregularities  in  the  bellies  of 
the  recti  muscles  for  new  growths.  The  latter  are  hard, 
nodular,  and  resistant  to  the  palpating  hand;  while  fecal 
tumors  yield  under  the  fingers  and  give  the  so-called  Ger- 
suny's  symptom,  that  is,  a  feeling,  after  pressure  on  the  mass, 
that  the  finger  still  adheres  to  the  tumor;  besides,  fecal 
tumors  usually  have  a  knotted  formation  and  shape,  and  are 
limited  largely  to  the  descending  colon  and  the  sigmoid  flexure. 

As  a  rule,  the  coils  of  the  small  intestine  are  not  palpable, 
but  the  examiner  may  often  observe  its  peristalsis  around 
the  umbilicus,  especially  in  women  who  have  relaxed  abdominal 
walls  and  who,  after  repeated  pregnancies,  have  diastasis  of 
the  recti  muscles  extending  from  a  finger's  to  a  hand's  breadth. 
These  visible  peristaltic  movements  of  the  small  intestine  are 
not  in  themselves  pathological,  and  are  unassociated  with 
neuroses  or  stenoses  of  the  small  intestine.  The  only  patho- 
logical features  in  such  a  case  are  the  above-described  condi- 
tions of  the  abdominal  wall. 

While  palpating  the  C2ecum,  a  gurghng  sound  is  fre- 
quently heard,  which  is  merely  a  sign  that  the  intestinal  con- 
tents are  of  a  fluid  consistency,  and  undergoing  fermentation. 

Hard,  irregularly-formed  tumors  are  frequently  palpated 
in  this  region,  and  are  usually  of  either  a  tubercular  or  a  car- 
cinomatous nature. 

To  palpate  the  vermiform  appendix,  the  physician  should  first  locate 
McBurney's  point, — which  lies  midway  between  the  umbihcus  and  the 
anterior-superior  spine  of  the  ilium.     He  should  place  the  palmar  surface 


DISEASES  OF  THE  INTESTINE  245 

of  the  fingers  of  the  left  hand  just  below  this  point,  at  right  angles  to  the 
line  from  the  umbilicus  to  the  anterior-superior  spine  of  the  ilium.  By  a 
slow,  downward  pressure  of  the  fingers,  accompanied  by  a  rolling  move- 
ment, the  appendix  will  frequently  be  felt  as  a  cartilage-like  band,  about 
the  length  of  the  little  finger  and  as  thick  as  a  lead  pencil,  which  can  be 
rolled  here  and  there  under  the  palpating  finger.  In  this  way,  with  ex- 
perience and  practice,  it  is  frequently  easy  to  demonstrate  whether  the 
appendix  is  SAVollen  and  sensitive,  or  elongated,  or  if  it  has  assumed  or  is 
retaining  an  abnormal  position. 

Palpation  should  not  be  concluded  until  the  abdominal 
rings  also  are  carefully  examined  for  hernia;  and  finally,  the 
rectum  and  anus  should  be  palpated  in  all  doubtful  cases. 

Percussion  should  be  used  by  the  physician  to  outline 
tympanitic  areas  of  the  abdomen. 

3.  Chemical  and  Microscopical  Examination  of  the  Stool 
No  detailed  nor  complicated  methods  of  examining  the  de- 
jections will  be  described  in  this  book,  but  only  such  procedures 
as  are  important  and  essential  to  the  practical  physician. 

a.  Macroscopical  Examination. — This  is  fully  as  valu- 
able as  the  microscopical  examination  of  the  stool;  and  indeed, 
for  the  general  practitioner,  it  is  often  the  only  possible 
method,  if  the  microscope  and  the  necessary  chemical  re- 
agents are  not  at  his  disposal. 

With  a  little  practice,  and  by  keeping  the  following  points 
in  mind,  the  physician  will  be  able  to  diagnosticate  correctly 
the  majority  of  chronic  affections  of  the  intestine  by  the 
examination  of  the  faeces  with  the  naked  eye  alone. 

1.  The  Form  of  the  Dejection. — It  has  already  been  men- 
tioned that  the  normal  stool  is  formed,  of  large  caliber,  and 
sausage-shaped;  and  also  that  with  vegetarians  it  may  nor- 
mally be  of  a  semi-solid  consistency. 

All  other  stools  are  pathological,  such  as  those  that  are 
spongy,  semi-solid,  liquid,  abnormally  hard,  or  of  small  caliber. 

2.  Color. — The  color  of  normal  faeces  may  range  from  yel- 
low to  brown.  Black  stools  are  caused  by  the  presence  of  blood, 
or  medicaments  such  as  iron  and  bismuth.  The  light-gray  stool 
is  indicative  of  liver-affections;  and  the  green,  of  acute  enteritis. 


246  DISEASES  OF  THE  DIGESTIVE  CANAL 

3.  Consistencii. — The  normal  consistency  of  the  stool  is 
about  that  of  butter  at  room-tcmperaturc.  Fieces  that  are 
hard  are  most  frequently  observed  in  atonic  constipation, 
while  they  may  l^e  still  liarder  in  spastic  constipation.  The 
stools  are  doughy,  s})ongy,  or  cream-like  in  mild  cases  of 
intestinal  catarrh;  semi-fiuid  to  fluid,  in  severe  cases;  and 
finally  of  watery  consistency,  in  Asiatic  cholera. 

4.  Food- Remnants. — Food-remnants  are  frequently  recog- 
nizable with  the  naked  eye;  for  instance,  bits  of  potato  or 
other  vegetables,  or  of  whortleberries,  mushrooms,  etc.,  all 
of  which  are  less  significant  in  diagnosis  than  undigested 
remnants  of  meat,  connective  tissue,  and  fats;  since  vegetable- 
remnants  are  found  in  every  normal  stool,  while  the  presence 
of  large  amounts  of  meat  and  connective  tissue  is  indicative 
of  disturbed  gastric  digestion. 

5.  Pathological  Constituents. — The  pathological  constitu- 
ents which  are  recognizable  with  the  naked  eye  are  blood, 
pus,  and  mucus. 

The  blood  varies  in  color  from  bright  red  to  tarry  black. 
If  the  former,  it  is  usually  free  and  not  mixed  with  the  faeces; 
when  of  the  latter  color,  its  origin  is  in  the  upper  portion  of 
the  gastro-intestinal  tract,  and  it  is  found  closely  admixed 
wath  the  stool.  Red  bloocl-cells  are  microscopically  demon- 
strable only  in  the  former  instance,  when  the  blood  is  fresh 
and  of  a  red  color.  In  the  latter  instance,  the  presence  of 
blood  must  be  chemically  proven. 

Bright  red  blood  in  the  stool  almost  always  comes  from  ruptured 
hemorrhoids  or  from  a  rectal  polyp.  When  blood  and  pus  are  found  in 
the  stool,  even  in  teaspoonful  amounts,  a  suspicion  should  always  be  aroused 
in  the  mind  of  the  physician  that  a  malignant  chsease  of  the  rectum  is  present. 
Carcinomata  of  the  rectum  are  often  treated  for  weeks  as  hemorrhoids. 

Pus. — In  tuberculosis  and  dysentery  of  the  colon,  and  in 
mahgnant  growths  of  the  colon  and  rectum,  pus  generally 
occurs  in  connection  with  blood. 

To  best  detect  pus,  the  examiner  should  spread  the 
entire  stool  as  thinly  as  possible  upon  a  smooth,  black  surface 
and  look  for  small  gray  points  with  the  aid  of  the  dissecting- 


DISEASES  OF  THE  INTESTINE 


247 


needle  or  a  wire  loop;   the  specimen  should  then  be  examined 
microscopically  for  leucocytes,  tubercular  bacilH,  etc. 

Mucus. — Small  amounts  of  mucus  are  present  on  the 
surface  of  the  normal  stool.  In  chronic  catarrh  of  the  colon, 
mucus  surrounds  the  entire  stool  like  a  membrane.  A  light- 
brown  mucus  is  often  evacuated,  together  with  semi-solid, 
unformed  dejections,  which  should  be  considered  as  an  objec- 
tive sign  of  severe  enteritis. 

Fig.  39. 


Normal  stool.     M,  muscle-fibres;  H,  plant-hairs;  F,  fat-globules;  B.  Z,   pear-cells;  Sj),  plant- 
spirals;  P.  Z,  plant-cells;  P,  Phosphate. 

The  membranous  form  of  mucus  is  always  from  the 
colon;  and  it  may  be  said  that  the  more  typical  the  membrane, 
the  lower  down  in  the  colon  is  its  origin.  Mucus  from  the 
ascending  colon  scarcely  ever  exceeds  the  size  of  a  pea.  When 
mucus  is  first  evacuated,  it  generally  has  the  appearance  of 
an  amorphous,  clumpy  mass,  but  its  membranous  character 
will  be  revealed  if  it  is  separated  with  forceps  or  a  needle  and 
shaken  out  in  water. 

Mucus  from  the  small  intestine  is  not  seen  macroscopically. 

In  catarrh  of  the  small  intestine,  the  stools  look  as  if  they 
had  been  varnished,  if  they  have  passed  rapidly  through  the 
colon  without  undergoing  changes  in  that  portion  of  the  gut. 
In  such  a  case,  the   superficial  surface  of  the  stool   appears 


248 


DISEASES  OF  THE  DIGESTIVE  CANAL 


smooth  and  reflective  after  it  has  stood  for  some  time.  In  this 
affection,  the  stool  is  often  soft,  porous  and  sponge-like. 

For  further  details,  see  the  chapter  on  Intestinal  Catarrh. 

6.  Concrements  and  Foreign  Bodies.- — The  stool  should 
always  be  examined  for  these  in  a  case  of  gall-stone  colic. 
The  entire  stool  should  be  stirred  with  warm  water  and  washed 
through  a  fine  sieve,  b}'  which  procedure  gall-stones  are  usually 
recognized.  The  Boas  stool-sieve  may  be  used  to  good  advan- 
tage for  this  purpose. 

Fig.  40. 


Stool  containing  fat  and  bismuth.     M,  muscle-fibres;    A'^,  fat-needles;  F,  fat-droplets;    B.K, 
bismuth-crystals;  O.K,  calcium  o.'ialate  crystals;  Ka,  calcium  salts. 

The  physician  must  always  guard  against  confusing 
vegetable-remnants,  and  especially  fruit-seeds,  with  gall- 
stones. The  suspected  bodies  should  be  placed  in  a  watch- 
crj^stal  containing  a  solution  of  liquor  potassse,  which  softens 
the  vegetable  tissue,  so  that  when  they  are  crushed  between 
two  cover-glasses  they  may  be  easily  recognized  with  the 
microscope.  On  several  occasions,  poppy  seeds  have  been 
brought  to  my  clinic  by  patients  who  thought  them  to  be 
biliary  concretions. 

Often  the  debris  formed  from  pears  very  closely  simulates 
concrements,  since  the  pear-tissue  contains  hard,  cellulose 
material  which  may  form  the  so-called  intestinal  gravel, 
whose  retention  might  produce  colic. 


DISEASES  OF  THE  INTESTINE 


249 


It  would  be  impossible  to  enumerate  the  various  foreign 
bodies, — such  as  coins,  buttons,  teeth,  pieces  of  bone,  fruit- 
seeds,  etc., — that  are  sometimes  found  in  the  stool. 

7.  Parasites. — Tapeworm,  Ascaris  lumbricoides,  etc.,  can- 
not escape  the  careful  macroscopical  examination  of  the  stool. 

h.  Microscopical  Examination  of  the  Stool. — 
Technic. — For  a  proper  examination  of  the  stool,  at  least 
three  preparations  should  be  made; 


Fig.  41. 


Enteritis.    M,  muscle-fibres;  H,  yeast-cells;  E,  epithelium;  CI,  Clostridia. 

1.  Dry. 

2.  With  the  addition  of  a  little  water  or  acetic  acid. 

3.  With  the  addition  of  Lugol's  solution. 

1.  A  portion  of  the  stool,  about  the  size  of  a  half  a  pea, 
should  be  pressed  as  flat  as  possible  between  two  cover- 
glasses  until  it  becomes  transparent,  and  should  then  be 
examined  with  the  low  power  of  the  microscope. 

By  this  method,  the  physician  will  inform  himself  con- 
cerning the  digestion  of  meat,  fats,  and  connective  tissue. 
Muscle-fibres  are  easily  recognized  by  their  yellow  color  and 
regular  surface.  They  are  present  in  every  normal  stool  and 
should  not  be  considered  as  pathological,  unless  almost  the 
entire  field  of  the  microscope  is  covered  with  them,  or  unless 


250 


DISEASES  OF  THE  DIGESTIVE  CANAL 


large  masses  of  the  muscle-fibres  appear  grouped  together. 
In  siich  a  case,  the  physician  may  assume  that  the  gastric 
digestion, — one  of  the  chief  functions  of  which  is  to  dissolve 
connective  tissue, — is  poor. 

If  a  large  number  of  isolated  muscle-fibres  are  present 
in  the  microscopical  fiehl,  it  sliould  l)c'  inferred  that  digestion 
in  the  small  intestine  is  not  normal. 


Fig.  42. 


T.  E.,  Taenia  solium;  Ch,  Charcot-Leyden  cry.stals;  M,  muscle-fibres;  F,  fat-droplets; 
A.E.,  eggs  of  ascarides;  //,  yeast;  E,  epithelium;  A'',  fat-needles. 

An  intense  yellowish-green  color  of  meat-fibres  is  indica- 
tive of  catarrh  of  the  ileum. 

In  normal  conditions,  only  a  few  fat-droplets  will  be 
found  in  the  stool.  But  in  cases  in  wdiich  there  is  catarrh  of 
the  large  or  of  the  small  intestine,  disease  of  the  pancreas  or 
any  pathological  conditions  in  which  there  is  an  obstruction 
of  the  ductus  choledochus  which,  because  of  the  absence  of  bile, 
gives  a  gray-white  color  to  the  stool, — the  entire  field  of  the 
microscope  may  be  full  of  fatty-acid  crystals,  needles,  fat- 
droplets,  and  even  clumps  of  fat. 

Connective-tissue  fibres  are  recognized  by  their  shining 
surface  and  their  tortuosity.  They  are  often  much  swollen. 
An  enormous  number  is  indicative  of  the  diminution  or  the 
entire  absence  of  hydrochloric  acid  in  the  gastric  juice. 


DISEASES  OF  THE  INTESTINE  251 

In  this  preparation,  the  eggs  of  intestinal  parasites  are 
also  recognized,  especially  those  of  tapeworms,  ascarides, 
and  the  trichocephalus. 

The  accompanying  cuts  will  illustrate  the  above  findings. 

2.  A  portion  of  the  fasces,  about  the  size  of  the  head  of 
a  pin,  should  be  mixed  with  a  drop  of  normal  sodium  chloride 
solution  and  examined  with  an  objective  of  higher  magnifica- 
tion. In  this  specimen,  the  examiner  will  likewise  observe  the 
degree  of  digestion  of  meat-fibre,  fat,  and  connective  tissue,  and 
will  also  note  the  presence  of  pus,  amoebae,  infusoria,  Charcot- 
Leyden  crystals,  epithelia,  and  red  and  white  blood-corpuscles. 

In  stools  of  fluid  or  semi-fluid  consistency,  the  physician 
should  examine  the  specimen  for  mucus,  without  the  addition 
of  a  sodium  chloride  solution  or  acetic  acid. 

Charcot-Leyden  ciystals  in  the  mucus  are  quite  typical  of 
helminthiasis. 

An  enormous  amount  of  epithelia  is  characteristic  of  chronic  intestinal 
catarrh.  If  a  severe  inflammatory  condition  of  the  intestinal  mucosa  is  pres- 
ent, numerous  white  blood-corpuscles,  in  addition  to  epithelia,  will  be  found. 

3.  A  portion  of  the  faeces  about  the  size  of  a  pin-head 
should  be  mixed  with  a  drop  of  Lugol's  solution.  Under  high 
magnification,  the  examiner  should  determine  whether  free 
starch-corpuscles  and  Clostridia, — which  are  both  colored  blue  by 
the  iodine  in  Lugol's  solution, — are  present  in  profuse  numbers. 

Free  starch-cells  are  always  a  sign  of  a  catarrhal  condition  of  the  small 
intestine.  Normally,  starch  is  only  found  enclosed  in  cellulose.  Clostridia 
are  always  a  sign  of  fermentation;  the  more  cellulose  the  food  contains, 
the  more  profuse  is  the  development  of  Clostridia,  which  give  a  sour  odor  to 
the  stool.  When  they  are  present  therefore  in  large  numbers,  the  examiner 
may  assume  a  pathological  condition  of  the  small  intestine. 

In  many  cases,  he  should  make  a  fourth  or  a  fifth  prep- 
aration from  parts  of  the  stool  presenting  some  unusual 
appearance;  for  example,  bloody  or  purulent  portions  (see 
Figs.  40  and  41). 

Frequently  it  happens  that  crystals, — such  as ,  triple 
phosphates,  calcium  oxalates,  etc., — as  well  as  large  numbers 
of  bacteria,  and  the  most  diverse  kinds  of  plant-cells,  which 


252  DISEASES  OF  THE  DIGESTIVE  CANAL 

are  easily  recognized  by  the  thick,  ghstcning  membrane,  are 
observed  under  the  microscope.  In  dilatation  of  the  stomach, 
sarcinir  are  also  found  in  the  firccs,  which  arc,  consequently,  of 
especial  importance  in  the  diagnosis. 

The  microscopical  examination  of  the  faeces  allows  us, 
therefore,  to  form  conclusions  concerning  the  following: 

1.  The    digestion    of    meat,   fat,   connective    tissue  and 

starch. 

2.  The  presence  of  blood,  mucus,  and  pus. 

3.  The    presence    of    concrements,    crystals,    ova    of    the 

various   parasites,   and   Charcot-Leyden   crystals. 

The  microscopical  examination  will  lead  to  a  correct 
diagnosis  only  in  connection  with  the  macroscopical  findings. 

c.  Chemical  Examination. — 1.  Test  for  Occult  Blood. — 
A  positive  reaction  to  this  test  is  of  value  only  when  very  few 
meat-fibres  are  present  in  the  stool. 

To  obtain  a  significantly  positive  result,  it  is  necessary 
that,  for  three  days  before  making  the  test,  the  patient  be 
kept  on  a  diet  which  does  not  contain  blood  or  iron. 

Either  the  Aloin-test  may  be  made,  which  has  been 
described  in  Part  I;  or  the  more  simple  and  sensitive  test, — 
recently  introduced  by  0.  and  R.  Adler,  and  modified  by 
Schlesinger  and  Hoist,— may  be  made  in  the  following  manner: 

1.  Dissolve  a  knifepoint  of  pure  benzidin  in  two  or  three  cubic  cen- 
timetres of  glacial  acetic  acid. 

II.  Add  2  c.c.  of  Hp^  to  ten  or  twelve  drops  of  "I." 

III.  Boil  a  portion  of  the  faeces  the  size  of  a  pea,  which  has  been  thor- 
oughly mixed  with  five  or  six  cubic  centimetres  of  water,  in  a  test-tube 
closed  with  a  wad  of  cotton. 

IV.  Add  two  or  three  di-ops  of  the  solution  of  boiled  faeces  to  "II." 
If  blood  is  present,  a  green  or  bluish  reaction  will  occur  in  from  one  to 
three  minutes. 

2.  Schmidt's  Biliruhin-T est. — A  portion  of  fseces  about  the  size  of  a 
bean  should  be  placed  in  a  watch-crystal  containing  a  5  per  cent,  sublimate 
solution,  and  alloAved  to  stand  for  twenty-four  hours.  At  the  end  of  this 
time,  ptfi'tions  of  the  stool  containing  bilirubin  will  have  become  green,  while 
those  containing  hydro-bilirubin  will  be  yellowish-red.  Positive  reactions 
of  either  are  indicative  of  a  catarrhal  condition  of  the  small   intestine. 


DISEASES  OF  THE  INTESTINE  253 

CLOSING    REMARKS    AND    DIRECTIONS 

Patients  whose  bowels  move  normally  may  bring  the 
stool  to  the  physician's  office  in  a  closed  glass  receptacle. 
Constipated  patients  should  produce  an  evacuation  of  the 
stool  by  using  a  soap  suppository,  the  stool  being  left  in  a 
vessel  half- filled  with  water,  for  the  inspection  of  the  physician. 
In  office-practice,  the  stool  may  be  conveniently  obtained  and 
preserved  by  the  use  of  the  apparatus  previously  described. 

PRIMARY  ORGANIC  DISEASE  OF  THE  INTESTINE 
Acute  Enteritis. 

General  Remarks. — In  considering  acute  intestinal  catarrh, 
which  occurs  with  great  frequency,  we  shall  discuss  the  sub- 
ject as  briefly  as  possible,  since  nearly  every  physician  is 
familiar  with  the  symptoms  and  treatment.  It  is  only  the 
severe,  chronic  cases  that  come  to  the  physician  for  treat- 
ment, as  the  milder  and  more  acute  ones  are  usually  relieved 
by  home  remedies. 

Acute  enteritis  becomes  serious,  as  a  rule,  only  in  children, 
or  in  old  and  decrepit,  or  arteriosclerotic,  persons.  It  occurs 
epidemically  during  the  summer  months,  as  is  well  known. 

The  entire  intestinal  tract  may  become  affected  or  only 
individual  portions  of  it,  such  as  the  duodenum  and  jejunum, 
when  the  inflammatory  process  extends  from  the  stomach, 
and  when  the  causative  agent  passes  through  the  stomach 
without  producing  inflammation  of  its  mucosa,  as  is  the  case 
with  certain  poisons  that  are  soluble  only  in  the  alkaline 
intestinal  juice.  The  mucosa  may  be  so  severely  inflamed  that 
ulceration  occurs,  the  stools  then  becoming  bloody  in  character. 

Etiology. — The  causes  of  acute  enteritis,  in  the  order  of 
their  frequency,  are  the  following: 

Indigestion,  infections,  intoxications,  and  exposure  to  cold. 

Foods  which  are  especially  injurious  in  acute  enteritis 
are  raw  fruit,  ice-cold  beer,  fresh  cucumbers,  sour  potatoes, 
and  meat-dishes,  especially  in  summer;  while  overloading  the 
stomach  with  fancy  dishes,  such  as  goose,  liver,  patties,  ra- 
gouts, etc.,  is  the  most  frequent  causal  factor  in  the  winter. 


254  DISEASES  OF  THE  DIGESTIVE  CANAL 

Besides  the  intoxications  resulting  from  attempted  sui- 
cide, murder,  criminal  abortions,  etc.,  there  should  be  men- 
tioned, as  causative  factors,  vermifuge  remedies  and  the 
occupation-poisons,  such  as  copper,  lead,  etc. 

Exposure  to  cold  causes  acute  catarrh  of  the  intestine, 
especially  when  the  resistance  of  the  mucosa  has  been  weak- 
ened by  previous  catarrhs. 

Symptomatology. — The  chief  symptom  is  diarrhoea,  which 
occurs  with  almost  explosive  suddenness  and  with  colic. 
It  is  not  rare  for  twenty  stools  to  be  passed  in  .24  hours,  al- 
though in  some  cases  constipation  results  from  spasm  of  the 
colon, — -first,  when  only  the  small  intestine  is  affected;  and 
second,  when  the  offending  material, — for  instance,  undigested 
remnants  of  food,  such  as  cucumbers,  sour  potatoes,  etc., — 
lodges  in  the  folds  of  the  mucous  membrane  of  the  colon, 
producing  spasm,  accompanied  by  severe  pain  from  the  result- 
ing irritation. 

Colic, — that  is,  gnawing,  boring,  contracting  pain, — 
begins  in  the  mesogastrium,  radiates  in  all  directions,  and 
disappears  with  a  movement  of  the  bowels  or  the  escape  of 
gas;  it  recurs  repeatedl}^,  and  accompanies  nearly  every  case 
of  enterocolitis. 

Fever  occurs,  as  a  rule,  only  in  infectious  enterocolitis. 
Indeed,  it  is  characteristic  of  this  form,  and  will  amount  to 
40°  C,  [104°  Fahr.]  or  more.  The  other  causative  agents  produce 
either  no  fever  at  all,  or  at  most  38.5°  C.  [101°  Fahr.].  Vomiting 
and  nausea  exist  only  when  the  stomach  also  is  involved. 

The  general  condition  of  the  patient,  even  in  moderately 
severe  enteritis,  is  poor.  In  very  severe  cases,  there  are  great 
weakness  and  lassitude,  caused  by  the  violent  pain. 

The  spleen  is  generally  swollen  and  sensitive  to  pressure, 
especially  in  infectious  enterocohtis.  Indeed,  the  whole 
abdomen  is  sensitive  to  pressure,  especially  over  the  course 
of  the  transverse  colon.  Icterus  is  often  an  accompanying  or 
subsequent  symptom.  The  stool  is  of  a  semi-solid  or  fluid 
consistency^  and  mixed  with  large  shreds  of  mucus  which  are 
often   tinged    with   blood.      Old,    hard   scybala   may   also    be 


DISEASES  OF  THE  INTESTINE  255 

passed.  The  odor  of  the  stool  is  at  first  very  penetrating  or 
acid,  later  it  is  stale  and  fiat.  The  color  may  be  brown,  green, 
yellow  or  light  gray.    Late  in  the  affection,  mucus  only  is  passed. 

Microscopic  examination  shows  the  presence  of  epithclia 
and  in  severe  cases  of  red  and  white  blood-corpuscles,  rem- 
nants of  food,  bacteria,  etc. 

Diagnosis. — The  diagnosis  is  made  from  the  sudden  onset 
of  the  above-mentioned  symptoms, — namely,  diarrhoea,  fever, 
colic,  mucus  and  blood  in  the  stools, — and  by  the  establish- 
ment of  an  etiological  factor. 

Differential  Diagnosis. — Typhoid  fever,  crises  enteriques, 
and  acute  yellow  atrophy  of  the  liver  are  the  most  common 
diseases  to  be  differentiated  from  acute  enterocolitis. 

There  are  cases  in  which  only  a  prolonged  observation  of 
the  disease  will  differentiate  enterocolitis  from  typhoid  fever, 
although  the  roseolse,  splenic  tumor,  and  the  general  condition 
will  usually  protect  the  physician  against  mistake. 

Treatment. — The  tasks  of  the  physician  are  largely 
limited  to  protecting  the  mucosa  of  the  intestine  from  further 
injury  as  much  as  possible,  and  to  controlling  the  pain  and 
diarrhoea. 

Rest  in  bed  is  essential  as  long  as  there  is  fever.  In  cases 
in  which  the  latter  is  high, — 39°  to  40°  C, — cold  applications 
should  be  used  on  the  abdomen.  In  moderate  fever, — 38°  to 
38.5°, — the  Priessnitz  compresses  are  indicated;  while  febrile 
cases  are  best  relieved  by  the  application  of  moist,  hot  com- 
presses wrung  out  of  chamomile  infusion,  etc. 

The  dietetic  treatment  for  the  first  two  or  three  days  is 
the  same  as  in  acute  gastritis, — peppermint  tea,  black  tea  with 
cognac,  gruels,  soups,  cocoa  cooked  in  water  or  red  wine, 
and  the  gradual  institution  of  rice  and  cereals  added  to  pigeon 
or  chicken  broths,  and  finally  chicken,  veal,  white  bread,  etc. 

Meats,  raw  fruits,  cold  drinks  and  vegetables  should  be 
forbidden  for  some  time. 

Medicinal  Treatment.— BeWadonna  should  be  used  for  tlie 
suppression  of  the  cramp-like  pain;  and  styptics  for  the 
control  of  tlie  diarrhoea,  as  in  the  following  prescriptions: 


256  DISEASES  OF  THE  DIGESTIA  E  CANAL 

1.  I^     Extracti  belladonnte  fouorum,  gr.  l-\     0.02-0.03 
Sig. — Three  or  four  times  daily. 

2.  r^     Extracti  belladonnte  folioruin,  gr.  J     0.02 

Tannocol,  gr.  xv  1.0 

Sig. — One  powder  three  or  four  times  daily. 

3.  ^,     Tannalbin,  tannigen  or  tannoform,  gr.  xv     1.0 
Sig. — Three  or  four  times  daily. 

Opium  and  its  preparations  should  be  strictly  forbidden, 
because  they  paralyze  the  peristalsis  of  the  bowels,  and 
thereby  prevent  the  evacuation  of  the  materia  peccans.  In 
contrast  to  the  effect  of  opium,  belladonna  relaxes  the  painful 
contraction  of  the  intestine,  while  leaving  the  peristalsis 
undisturbed. 

I  administer  a  laxative  only  when  the  fever  is  higher 
than  38.5°  C,  and  has  continued  more  than  three  days.  In 
children  or  adults  w^th  good  teeth,  I  prefer  to  give  0.03  to 
0.2  [h  gr.  to  3  gr.]  calomel  three  times,  at  about  one-hour 
intervals,  or  until  the  desired  effect  is  produced.  In  other 
cases,  I  administer  either  a  teaspoonful  of  castor  oil  or  a  heap- 
ing teaspoonful  of  Carlsbad  salts. 

In  cases  in  wdiich  there  is  no  fever,  I  do  not  prescribe 
a  laxative  unless  the  cramp-like  pain  does  not  disappear. 
Otherwise,  I  prescribe  muriatic  acid  mixture. 

Constipating  remedies  should  not  be  given  unless  the 
fever  has  entirely  disappeared,  or  is  only  slight,  since  other- 
wise the  inflammatory  process  and  the  clinical  symptoms 
would  be  prolonged. 

Prophylaxis. — Individuals  who  seem  to  have  a  pre- 
disposition to  enterocolitis  should  be  warned  against  raw 
fruit,  cold  beer,  cucumbers,  sweets,  over-eating,  etc. 

Prognosis. — The  prognosis  of  the  disease  is  generally 
good,  although  there  always  remains  a  certain  weakness  of 
the  mucous  membrane  of  the  intestine. 

It  should  finally  be  mentioned  that  repeated  attacks  of 
acute  catarrh  often  lead  to  chronic  enterocolitis. 


DISEASES  OF  THE  INTESTINE  257 

Chronic  Catarrh  of  the  Intestine 

(Chronic  Enterocolitis) 

General  Remarks. — Chronic  catarrh  of  the  intestine  is 
very  frequent  in  old  people,  and  less  so  in  children.  Men  are 
more  often  affected  than  women,  because  they  are  exposed  to 
a  greater  number  of  injurious  influences. 

The  disease  may  extend  over  several  decades.  Indeed, 
severe  cases  are  never  cured  in  the  anatomical  sense;  and 
several  years  of  the  most  careful  treatment  are  required  to 
produce  even  a  clinical  cure. 

As  a  general  thing,  the  beginning  of  the  affection  is 
generally  entirely  neglected,  so  that  the  disease  gradually 
becomes  worse  until  finally,  on  account  of  the  suffering  due 
to  constant  pain,  flatus,  and  diarrhoea,  the  patient  consults 
a  physician. 

Etiology. — Primary  intestinal  catarrh  is  caused  by  direct 
injury  to  the  intestinal  mucous  membrane,  while  secondary 
catarrh  is  caused  by  passive  congestion  brought  on  by  venous 
stasis  in  the  greater  or  the  lesser  circulatory  systems,  or  by 
the  continuity  of  inflammation  from  neighboring  organs. 

Primary  catarrhal  enterocolitis  arises  from  indigestion, 
infections, — such  as  tuberculosis,  dysentery,  etc., — intoxica- 
tions, exposure  to  cold,  misuse  of  laxatives,  entozoa,  habitual 
constipation,  and  mechanical  irritation  from  scybala. 

Secondary  enterocolitis  results  from  cardiac  diseases, 
affections  of  the  kidneys,  sclerosis  of  the  liver,  and  from 
ulceration,  tumors,  and  stenosis  of  the  intestine. 

The  most  common  cause  of  chronic  enterocolitis  is  fre- 
quent indigestion,  in  consequence  of  which  chronic  catarrh  of 
the  stomach  and  of  the  intestinal  tract  both  occur. 

As  a  rule,  chronic  gastritis  precedes  chronic  enterocolitis. 
It  very  frequently  happens  that  catarrh  of  the  intestinal 
tract  is  secondary  to  atrophy  of  the  gastric  glands,  the  so- 
called  achylia  gastrica,  when  the  food  enters  the  duodenum 
non-chymified,  and  this  in  the  course  of  years  produces 
chronic  inflammation. 

17 


258  DISEASES  OF  THE  DIGESTIVE  CANAL 

Naturally,  both  affections  may  arise  at  the  same  time 
and  from  the  same  cause, — as,  for  instance,  from  the  excessive 
use  of  alcohol.  For  this  reason,  the  gastric  juice  should  be 
examined  in  every  case  of  chronic  enterocolitis. 

Symptomatology. — The  subjective  s3''mptoms  are  loss 
of  appetite,*  nausea,  feeling  of  fulness,  and  distention  of  the 
entire  abdomen  which,  in  contrast  to  the  same  sj'mptoms  in 
gastric  diseases,  appear  earl}'  in  the  morning,  are  of  only  short 
duration,  and  are,  except  for  flatuous  foods,  independent 
of  eating. 

Other  symptoms  more  characteristic  of  this  disease  are 
flatulence,  colic  or  the  so-called  mesogastralgia,  and  frequent 
tenesmus.  Lassitude,  weakness,  lack  of  desire  to  work,  and 
nervous  irritabilit}^  are  present  in  enteritis. 

Objective  Symptoms. — By  palpation  and  an  accurate 
examination  of  the  stools,  the  physician  will  find  the  most 
typical  signs  and  symptoms. 

The  whole  abdomen  is  frequently  distended  and  sensi- 
tive to  pressure,  especially  over  the  entire  course  of  the  colon, 
whose  sensitiveness  in  a  localized  inflammation  of  the  large 
intestine  is  characteristic. 

Enlargement  of  the  spleen  is  sometimes  found  in  a  catarrh 
which  has  existed  for  years. 

The  condition  of  the  stools  depends  upon  the  intensity 
and  the  localization  of  the  inflammatory  process  of  the  intes- 
tinal tract. 

In  mild  cases,  the  stools  are  of  firm  consistency,  have  a 
small  caliber,  and  are  surrounded  with  membranous  mucus. 

In  cases  of  moderate  severity,  their  condition  is  variable, 
— solid  and  liquid  stools  alternating  with  each  other,  or  with 
those  of  a  pulpy  consistency. 

In  the  more  severe  cases,  the  stools  are  persistently  semi- 
solid, semi-fluid,  or  liquid,  and  are  mixed  with  large  shreds  of 
mucus.  The  superficial  surface  of  the  stools,  of  pulpy  con- 
sistency is  reflective,  having  a  varnished  appearance. 

*  This  does  not  occur  in  some  cases;  for  instance,  in  gormands  suffering 
from  intestinal  catarrh,  the  appetite  is  often  excellent. 


DISEASES  OF  THE  INTESTINE  259 

When  ulcerations  or  erosions  arc  associated  with  catar- 
rhal inflammation,  the  stools  are  often  mixed  with  bloody, 
purulent  mucus. 

There  are  cases  of  enterocohtis  in  which  the  clinical 
course  is  characterized  by  periods  of  complete  constipation 
alternating  with  severe  diarrhoea. 

Further  details  have  been  given  in  a  previous  chapter 
on  Macroscopical  Examination  of  the  Stools. 

Diagnosis. — The  diagnosis  of  catarrh  of  the  intestine  is, 
in  general,  very  easy.  The  statements  of  the  patients  often 
suffice  as  to  whether  they  have  a  diarrhoea  which  is  persistent 
or  frequently  recurrent,  whether  it  occurs  only  after  eating 
certain  foods,  whether  mucus  is  present  in  the  stools,  and 
whether  or  not  they  suffer  from  colic. 

The  Localization  of  the  Lesion.— This  is  often  very  difficult, 
and  in  many  cases  quite  impossible,  although  the  following 
suggestions  will  generally  be  found  appHcable  in  the  diagnosis. 

Inflammation  Hmited  to  the  small  intestine  causes  loss  of 
appetite,  borborygmus,  a  gnawing  sensation  in  the  middle  of 
the  abdomen,  meteorism,  or  flatulence;  while  actual  pain  and 
diarrhoea  occur  but  rarely.  The  stools  contain  much  fat  and 
sometimes  free  starch-cells  and  many  muscle-fibres,  while  mu- 
cus is  scarcely  ever  recognized,  even  with  the  microscope. 
The  condition  is  aggravated  by  the  use  of  flatuous  foods,  cold 
drinks,  raw  fruit,  and  by  overloading  the  stomach. 

The  diagnosis  of  catarrh  of  the  ileum  is  arrived  at  largely 
from  accurate  statements  made  by  the  patient  in  the  anam- 
nesis. The  stools  are  formed,  are  of  soft  consistency,  and  the 
bowels  are  regular. 

Catarrh  limited  to  the  colon  runs  a  clinical  course,  as  a 
rule,  with  constipation,  or  a  sluggish  condition  of  the  bowels 
with  the  evacuation  of  spastic  stools,  unless  an  ulcerative 
process  is  present.  Only  in  severe  cases  are  the  stools  of  large 
cahber  and  of  a  pulpy  consistency,  when  they  are  surrounded 
by  membranous  mucus,  which  is  frequently  not  recognized 
until  the  stool  has  been  placed  in  a  vessel  of  warm  water.  In 
the  event  that  the  stool  is  brought  to  the  physician  in  a  dry 


^260  DISEASES  OF  THE  DIGESTIVE  CANAL 

glass  receptacle,  the  mucus  may  no  longer  be  recognizable, 
because  of  its  having  become  dry.  If  constipation  is  present, 
it  will  be  necessary  to  insert  a  soap-suppository  in  the  rectum 
of  the  patient  in  order  to  obtain  the  stool  for  examination. 

Catarrh  of  the  entire  intestinal  tract,  that  is,  of  the  large 
and  small  intestine,  almost  always  runs  a  clinical  course  with 
diarrhcea.  The  more  extensive  and  severe  the  inflammatory 
process,  the  more  severe  is  the  diarrhoea, — there  being  often 
from  two  to  six  stools  in  twenty-four  hours.  If  the  dejections 
are  still  more  frequent,  the  clinician  should  think  of  ulceration 
of  the  intestine,  and  should  direct  the  examination  of  the 
patient  accordingly.  In  chronic  cases,  a  movement  of  the 
bowels  is  especially  frequent  early  in  the  morning,  probably 
caused  by  the  fermentation  of  the  faeces  during  the  night. 
Mucus  in  large  or  moderate  amounts  is  almost  always  present 
in  the  dejections,  and  in  fluid  stools  is  detected  in  pea-sized 
portions,  and  may  be  removed  with  a  teasing-needle  or  forceps 
and  shaken  out  in  water,  when  it  is  easily  recognized. 

The  so-called  ileoctecal  catarrh,  which  at  the  same  time 
attacks  the  greater  part  of  the  ascending  colon,  runs  a  clinical 
course  with  the  above-mentioned  symptoms  and  with  persist- 
ent sluggishness  of  the  bowels,  sometimes  complete  constipa- 
tion, or  profuse  diarrhoea  accompanied  by  severe  pain.  Objec- 
tively, the  examiner  will  find  gurgling  murmurs  in  the 
ileocsecal  region. 

Catarrh  of  the  large  intestine  almost  invariably  runs  a 
clinical  course  with  cramp-like  pain,  mucus  in  the  stools,  and 
"wind-cohc." 

In  general  work,  the  physician  must  be  satisfied  with 
the  determination  as  to  whether  slight,  moderate,  or  very 
severe  catarrh  of  the  intestine  is  present,  because  an  exact 
localization  of  the  lesion  is  often  possible  only  after  pro- 
longed clinical  observation  and  a  microscopical  and  chemical 
examination  of  the  faeces. 

Differential  Diagnosis. — Nervous  diarrhoea  is  almost  the 
only  affection  that  might  be  confused  with  chronic  entero- 
colitis.    This  is  extremely  rare,   however,   and  can  only  be 


DISEASES  OF  THE  INTESTINE  261 

diagnosticated:  jSrst,  when  the  dejections  contain  no  macro- 
scopically  visible  mucus;  and  second,  when  diarrhoea  occurs 
invariably  after  any  excitement.  In  almost  every  case  of 
nervous  diarrhoea,  there  exists  a  latent  catarrhal  condition 
as  the  basis  of  the  trouble,  which  fact  should  always  be  kept 
in  mind  in  the  treatment,  because  many  so-called  nervous 
diarrhoeas  are  cured  only  by  anti-catarrhal  therapy. 

Ulcers  and  erosions  of  the  mucous  membrane  may  be 
differentiated  from  chronic  enterocolitis  by  the  absence  of 
blood  and  pus  in  the  dejections  of  the  latter. 

In  every  instance,  the  etiological  factor  should  be  ascer- 
tained if  possible,  and  the  following  three  points  should  be 
given  especial  attention: 

1.  Whether  the  gastric  secretion  is  normal;    or  whether 

there    is    present,    for   instance,    achylia    or    hyper- 
secretion. 

2.  Whether   the    catarrhal    condition   is    due   to   venous 

congestion. 

3.  Whether  there  is  a  malignant  affection  accompanying 

the  enterocolitis. 

Treatment. — The  first  task  in  the  therapy  is,  naturally, 
the  removal  of  all  etiological  factors,  so  far  as  possible,  and 
the  careful  study  of  the  functions  of  the  heart,  liver,  and 
stomach.  An  examination  of  the  contents  of  the  stomach 
must  be  made,  when  possible,  in  every  case  of  chronic  entero- 
colitis. Otherwise  it  often  happens  that  for  months  the  thera- 
peutic measures  will  produce  no  result.  Concerning  this 
point,  the  reader  is  referred  to  the  section  on  Chronic  Gastritis. 

In  the  following  discussion,  I  have  divided  cases  of  chronic 
enterocoHtis  into  three  groups: 

1.  Mild  cases,  with  either  constipation  or  normal  stool, 

and  with  many  disturbances  of  the  small  intestine. 

2.  Moderately   severe   cases,    with   alternating   constipa- 

tion and  diarrhoea. 

3.  Severe  cases,  with  persistent  diarrhoea. 


262  DISEASES  OF  THE  DIGESTIVE  CANAL 

Hygienic  and  Dietetic  Treatment. — In  all  forms  of  intes- 
tinal catarrh,  any  sudden  exposure  to  cold  and  chilling  of  the 
abdomen,  feet,  or  entire  body  should  be  avoided.  The  patient 
should  wear  woolen  underclothing  and  a  woolen  abdominal 
bandage  during  the  day  and  a  Pricssnitz  compress  at  night. 
Workingmen  should  avoid,  as  much  as  possible,  occupations 
which  give  rise  to  intestinal  catarrh,  especially  those  in  which 
they  come  into  frequent  contact  with  arsenic,  lead,  copper  or 
mercury.    Only  a  limited  amount  of  smoking  should  be  allowed. 

The  diet  in  chronic  enterocolitis  must  be  bland,  non- 
irritating  and  easy  of  absorption;  and  in  severe  cases,  it 
should  be,  in  addition  to  the  above,  astringent  in  character, 
and  consist  of  the  following:  Tea  with  one  tablespoonful  of 
cream,  red  wine,  cocoa  or  blackberry  wine;  cereal  soups, 
gruels,  rice,  sago,  noodles,  macaroni;  the  broth  of  white  meats, 
fresh  soft  eggs,  toasted  white  bread,  Leibniz's  cakes,  butter; 
and  milk  diluted  one-half  with  cereal  soups  or  cocoa,  but 
never  undiluted. 

In  cases  of  moderate  severity,  the  patients  may  be 
allowed,  in  addition  to  the  above,  light  vegetables, — such  as 
spinach,  carrots,  cauUflower,  asparagus,  peas,  potato  purees, 
and  red  meats  cooked  in  butter  or  broiled. 

In  Kght  cases,  the  dietary  may  include  whole-wheat 
bread,  stewed  fruit-sauces,  meats,  fish,  and  the  like.  In  this 
form,  it  is  unnecessary  to  adhere  strictly  to  any  special  dietary. 
Only  the  following  foods  are  forbidden:  cold  drinks,  strong 
coffee,  plain  milk,  sour  milk,  all  acid  foods,  raw  fruits, — such 
as  sweet  oranges,  dates,  figs,  and  apples — legumes,  cheese, 
cabbage,  smoked  meats  and  fish,  fat  meats,  fresh  bread,  and 
pastries.     Special  diet-tables  will  be  found  in  the  Appendix. 

The  mechanical  treatment  consists  in  warm  or  hot 
injections. 

In  severe  cases,  associated  with  diarrhoea,  in  which  treat- 
ment per  mouth  is  not  successful  in  controUing  the  bowels, 
I  generally  prescribe  the  following  enema,  night  and  morning: 

One  teaspoonful  of  tannin,  1  tablespoonful  of  starch 
and  1  ntre  of  water  32°  to  33°  R.  [104°-10()°  F.];   or  a  solution 


DISEASES  OF  THE  INTESTINE  263 

of  silver  nitrate,  0.5  to  1.0  [gr.  viiss  to  xv]  to  1000,  or  one 
tablespoonful  of  the  extract  of  blackberry  to  |-  litre  of  water. 

Since  many  astringent  preparations  should  be  employed 
with  considerable  caution,  their  use  is  limited  to  the  chnic; 
but  the  tannin-starch  enema  may  be  prescribed  without 
hesitation  for  home  treatment. 

In  moderate  cases,  an  injection  of  one  litre  of  hot  Carls- 
bad water  or  a  htre  of  hot  water  containing  a  teaspoonful  of 
the  artificial  Carlsbad  salts,  should  be  given  every  morning. 

Under  this  treatment,  the  cramp-like  pain  and  the  diar- 
rhoea disappear  with  surprising  quickness  in  a  great  number 
of  cases,  because  of  the  soothing  effect  upon  the  irritated 
membrane. 

In  mild  cases,  enemata  are  unnecessary.  . 

Massage  is  contraindicated  in  all  cases.  However,  a 
very  gentle  stroking  massage  may  be  allowed  if  there  is 
neurasthenia. 

Balneological  Treatment. — Balneological  treatment  depends 
first  upon  the  condition  of  the  stomach;  and  second,  upon 
the  intensity  of  the  enterocolitis. 

If  there  is  a  deficiency  of  gastric  secretions,  the  sodium 
chloride  waters  of  Homburg,  Wiesbaden,  or  Kissingen  [Cham- 
pion and  Hawthorn  Springs,  Saratoga,  N.  Y.,  and  Blue  Lick 
Springs,  Kentucky],  are  indicated.  In  mild  cases,  when  there 
is  either  a  normal  or  a  sluggish  condition  of  the  bowels,  the 
above-mentioned  waters  should  be  given  lukewarm;  in 
moderate  cases,  at  the  temperature  of  the  body;  and  in  severe 
cases,  as  hot  as  possible,  but  in  very  small  doses. 

On  the  other  hand,  when  there  is  normal  acidity  of  the 
gastric  juice,  or  hyperchlorhydria, — as  in  acid  gastritis, — the 
waters  of  Carlsbad,  Neuenahr,  Franzensbad,  Marienbad,  or 
Vichy  [Tate  Epsom  Water,  Tennessee;  French  Lick  Springs, 
Indiana;  Buffalo  Lithia  Water,  Virginia;  Crab  Orchard, 
Kentucky],  should  be  prescribed  in  the  same  quantities  and  at 
the  same  temperature  as  described  above.  Well  nourished  indi- 
viduals should  be  sent  to  Carlsbad,  while  anaemic  and  badly- 
nourished  patients  should  be  given  the  milder  Vichy  water. 


^204  DISEASES  OF  THE  DIGESTIVE  CANAL 

Two  or  three  glasses  of  the  water  shoiihl  be  drunk  each 
da}', — two  glasses  on  the  empt}'  stomach  early  in  the  morn- 
ing, and  one  glass  before  the  evening  meal.  The  spring- 
water  salts,  or  the  artificially  prepared  salts  dissolved  in  plain 
water,  may  be  used  as  above  indicated,  by  patients  who  are 
travelling  or  those  who  cannot  afford  the  luxury  of  a  visit 
to  one  of  these  watering  places. 

In  enterocohtis  associated  with  constipation,  either  | 
of  a  teaspoonful  of  Carlsbad  salts  or  H  teaspoonfuls  of 
Vichy  salts  should  be  dissolved  in  I  litre  of  water  and  taken 
on  the  empty  stomach  early  in  the  morning. 

These  mineral  water  treatments  should  be  continued  from 
four  to  six  weeks  and  begun  again  after  an  intermission  of  two 
or  three  months,  and  so  on  for  several  consecutive  j^ears;  for  it 
is  impossible  to  produce  a  complete  cure  in  one  course  of  treat- 
ment when  an  intestinal  catarrh  has  existed  for  several  years. 

Medicinal  Treatment. — The  control  of  pain  and  the  regu- 
lation of  the  bowels  are  the  indications  for  medicinal  treatment. 
I  prescribe  astringents  only  in  cases  of  persistent  diarrhoea. 
The  most  suitable  of  such  preparations  are  tannin  and  bismuth, 
although  tannocol,  tannalbin,  tannoform,  and  tannigen  have 
given  very  good  results  in  doses  of  a  knifepoint  to  one-half  a 
teaspoonful  three  times  daily.  Bismuth  subnitrate,  bitannate 
of  bismuth,  bismutose,  and  nosophen  may  also  be  useful,  while 
dermatol  is  particularly  suitable  in  tuberculosis  of  the  intestine. 
For  cases  in  which  the  stools  are  persistently  of  a  pulpy,  semi- 
solid consistency  with  marked  fermentation,  calcium  salts 
combined  with  bismuth  are  the  most  effective.  Good  results 
are  obtained  from  the  use  of  the  following  prescriptions: 

1.  I^     Calcii  carbonatis, 

Calcii  phosphatis,  aa,  ovi         25.0 

Bismuthi  salicylatis,  gr.  Ixxx     5.0 

M.  Sig. — One  teaspoonful  after  meals. 

2.  I^     Tannocol, 

or  Tannalbin, 
or  Tannigen, 

or  Bismuthi  subnitratis,  gr.  viiss-xv       0.5-1.0 
Sig. — T.i.d. 


DISEASES  OF  THE  INTESTINE  265 

The  most  efficient  sedative  and  anodyne  remedies  are 
belladonna,  menthol,  valerian,  and  the  carminatives.  I 
administer  them  in  the  following  prescriptions : 

1.  I^     Extract!  belladonna3  foliorum,  gr.  vii     0.5 

M.  ft.  pil.  No.  XXX.     Sig. — One  pill  after  meals,  t.i.d. 

2.  I^     Menthol,  gr.  iss     0.1 
Ft.  pil.  i.     Sig.— T.i.d. 

3.  I^     Spiritus  menthse  piperitse,  gtt.  Ixxx       5.0 

Tincturse  belladonnse  foliorum,  oiiss  10.0 
Tincturge  valeriana3,  oiv  15.0 

M.  Sig. — Thirty  drops  in  a  cup  of  hot  water  or  fennel 
tea,  t.i.d. 

4.  I^     Extracti  belladonnse  foliorum,  gr.  ivss     0.3 

Menthol,  gr.  xv  1.0 

Tincturse  Valerianae,  q.s.  ad  oi  30.0 

M.  Sig. — Twenty-five  drops  t.i.d. 

The  treatment  of  chronic  intestinal  catarrh,  because  of 
its  diversity  of  symptoms,  requires  much  experience  and  the 
art  of  individualizing.  The  physician  must  not  change  from 
one  line  of  treatment  to  another  merely  if  there  is  no  apparent 
improvement  in  two  or  three  weeks;  for  instance,  having 
given  the  mineral  water  for  this  length  of  time,  he  should 
not  change  to  astringents,  nor  vice  versa,  as  the  first  line  of 
treatment  has  not  been  given  a  sufficiently  thorough  trial. 

Prognosis  and  Course. — The  treatment  of  chronic  intes- 
tinal catarrh  should  extend  over  several  years;  indeed  many 
patients  must  adhere  strictly  to  a  suitable  dietary  for  the 
rest  of  their  lives  if  they  are  to  remain  free  from  intestinal 
disturbances,  as  relapses  are  likely  to  occur  after  the  slightest 
error  in  diet  or  exposure  to  cold.  As  a  rule,  improvement  is 
only  very  gradual. 

All  patients  suffering  from  chronic  enteritis  become 
nervous  and  hypochondriacal,  which  further  modifies  the 
prognosis  and  complicates  the  course  of  the  disease. 

APPENDIX 

1.  Membranous  Enteritis. — Membranous  catarrh  of  the 
colon,  which  is  still  designated  by  some  authors  as  "myxo- 
neurosis intestinalis, "  is  in  reality  a  simple,  chronic,  reparable, 


266  DISEASES  OF  THE  DIGESTIVE  CANAL 

superficial  catarrh  of  the  colon  which  accompanies  chronic 
constipation,  as  will  be  shown  in  its  clinical  description. 

Since  constipation  is  associated  with  neurasthenia  in  a 
large  majority  of  cases,  especially  women,  it  follows  therefore 
that  membranous  enteritis  is  also  met  with  in  hysterical  and 
neurasthenic  patients. 

Membranous  enteritis  disappears  as  soon  as  constipation 
is  cured,  which  fact  is  the  best  refutation  of  the  theory  of  its 
nervous  origin,  since  notwithstanding  the  cure  of  constipa- 
tion, the  hysteria  and  neurasthenia  often  become  still  more 
aggravated  and  persistent. 

Mucous  colic,  or  the  colica  mucosa  of  Nothnagel,  is  an 
acute  exacerbation  of  chronic  membranous  colitis.  For 
further  details,  see  the  subsequent  chapter  on  Chronic 
Constipation. 

2.  Meteorism  and  Flatulence  (Intestinal  Flatulent  Dyspep- 
sia).— By  meteorism,  we  designate  the  acute  abnormal 
distention  of  the  abdomen;  by  flatulence,  the  chronic 
abnormal  fermentation  and  evacuation  of  gas.  Although 
both  are  often  observed  in  nervous,  and  especially  in  hyster- 
ical, individuals,  they  are, — with  the  exception  of  obstruction 
of  the  bowels, — symptoms  of  catarrh  of  the  intestine  and  not 
of  a  nervous  affection. 

The  escape  of  gas  from  the  bowels  is,  in  itself,  normal; 
we  speak  of  a  pathological  flatulence  onl}'  when  the  patient 
suffers  from  discomfort,  such  as  cutting  pains,  disagreeable 
distention,  and  fulness  in  the  abdomen, — especially  when 
unable  to  expel  the  gas. 

The  retention  of  gas  causes  very  unpleasant  conditions 
and  symptoms, — such  as  mental  clulness,  palpitation  o£  the 
heart,  dyspnoea,  mental  depression,  insomnia,  irregularity  of 
the  appetite,  inabihty  to  work,  and  griping  pains  in  the  entire 
abdomen,  especially  in  the  flexures  of  the  colon. 

Whether  these  symptoms  are  of  a  reflex  nature, — caused 
by  the  .irritation  of  the  splanchnic  nerve, — or  are  the  result  of 
a  so-called  autointoxication — as  many  authors  assume — I 
shall  not  attempt  to  decide. 


DISEASES  OF  THE  INTESTINE  267 

The  cause  of  abnormal  accumulation  of  gas  in  the  intes- 
tine is  the  stagnation  and  fermentation  of  liquid  faeces,  which 
are  mixed  with  a  pathological  secretion  of  the  intestine, — 
namely,  mucus. 

In  simple  constipation  without  catarrh,  such  as  atonic 
constipation,  flatulence  does  not  occur,  nor  in  cases  of  severe 
catarrh  with  profuse  diarrha-a,  for  the  reason  that  in  each  of 
these  affections  there  is  present  only  one  of  the  two  conditions 
essential  to  the  formation  of  gas, — namely,  constipation  and 
mucus.  Flatulence,  however,  becomes  a  symptom  in  catar- 
rhal conditions  of  the  jejunum,  ileum,  and  large  intestine  as 
soon  as  the  colon  becomes  spastic,  as  is  very  frequently  tte 
case.  The  spasm  of  the  colon  does  not  permit  the  gas  to  escape 
at  all,  or  only  with  great  difficulty,  and  then  associated  with 
pain  {colica  flatulenta) ;  and  the  same  condition  of  the  colon 
offers  a  hindrance  to  the  expulsion  of  the  fermenting  liquid 
contents  of  the  ileum  into  the  colon,  or  out  of  the  caecum 
and  ascending  colon  into  the  transverse  portion  of  the 
large  intestine. 

The  principal  locations  of  fermentation  and  the  accumu- 
lation of  gas  are  the  caecum  and  the  ascending  colon,  where 
the  pathological  faeces  stagnate.  If  the  fermenting  contents 
of  the  bowels  enter  the  transverse  or  the  descending  colon, 
the}^  are  either  rapidly  evacuated  or  become  so  thickened 
by  absorption  that  the  fermentation-process  is  entirely  absent, 
or  slight,  for  the  reason  that  fermentation  is  present  only  to 
a  minimum  degree  in  dry  faeces. 

The  well-known  meteorism  which  occurs  in  hysterical 
patients  arises  from  spasm  of  the  colon  and  fermentation  of 
the  stagnating  catarrhal  and  liquid  contents  of  the  ileum. 
It  generally  occurs  in  hysterical  persons  with  enteroptosis, 
who  have  suffered  for  years  from  chronic  constipation,  in 
consequence  of  which,  as  we  shall  see  in  the  chapter  on  this 
subject,  secondary  catarrh  of  the  intestine  has  developed. 

It  is  an  indication  of  flatulent  dyspepsia,  when  distention 
and  pain  are  reheved  by  the  escape  of  gas.  It  is  often  neces- 
sary to  question  the  patient  carefully  concerning  this  point, 


268  DISEASES  OF  THE  DIGESTIVE  CANAL 

since  he  usually  considers  and  explains  the  pain  to  be  due  to 
"stomach-cramps"  and  ''pressure  in  the  stomach." 

Flatulence  is  especially  marked  after  the  use  of  flatuous 
foods,  such  as  all  kinds  of  fresh  fruits,  cabbage,  legumes, 
coarse  bread,  pastry,  fresh  beer,  and  other  cold  drinks.  The 
more  cellulose  the  food  contains,  the  more  troublesome  is  this 
symptom. 

That  persons  in  normal  health  have  more  or  less  flatu- 
lence is,  of  course,  well  known,  and  has  no  especial  significance. 

Diagnosis.  —  The  diagnosis  of  flatulence-  cannot  be 
mistaken  if  the  examiner  will  keep  in  mind,  in  a  case  of 
acute  meteorism,  the  possibility  of  intestinal  stenosis  or 
obstruction. 

Treatment. — The  therapy  of  this  symptom-complex, — - 
which  is  not  sufficiently  appreciated  nor  considered  in  the 
text-books  on  the  subject, — is  as  difficult  as  it  is  important 
in  general  practice. 

The  first  task  of  the  physician  should  be  to  cure  the 
chronic  catarrh  of  the  intestine,  or  rather  to  mitigate  its 
symptoms,  since  he  can  scarcely  hope  for  a  complete  cure  of 
chronic  enteritis;  second,  to  limit  the  use  of  fermentable 
foods;  third,  to  facilitate  the  removal  of  intestinal  gases. 
These  indications  are  best  fulfilled  by  the  following  treatment: 

1.  It  should  be  emphasized  that,  in  cases  where  all  the 
above  indications  are  estabfished,  we  invariably  have  to  do 
with  sfight  or  only  moderately  severe  enterocohtis, — and 
never  the  severe  form  of  the  disease;  for  in  the  latter,  owing 
to  persistent  diarrhoea,  there  is  no  stasis  of  the  intestinal 
contents,  while  in  slight  and  moderately  severe  cases,  the 
enterocolitis  is  associated  with  constipation  of  a  spastic  nature, 
or  with  alternating  diarrhoea  and  constipation. 

Anti-catarrhal  mineral  water  should  be  prescribed, — 
small  doses  of  Carlsbad,  Vichy,  or  Homburg  waters,  accord- 
ing to  the  principles  set  forth  in  a  previous  chapter;  or  else 
the  anti-fermentative  remedies  that  are,  at  the  same  time, 
astringent  to  the  mucous  membrane  of  the  intestine, ^such 
as  tannocol,  tannalbin,  menthol,  resorcinol,  vegetable  charcoal 


DISEASES  OF  THE  INTESTINE  269 

(one  teaspoonful  three  times  daily),  or  the  calcium  salts, — 
according  to  the  following  prescriptions: 

1.  I^     Tannalbin,  oiiss     10.0 

Sig. — Four  to  eight  grains,  t.i.d. 

2.  I^     Calcii  carbonatis, 

Calcii  phosphatis,  aa,  5vi     25.0 
M.  Sig. — One  teaspoonful,  t.i.d. 

When  there  is  constipation,  mineral  water  should  be 
given  at  a  temperature  of  28°  to  30°  R.  [96°  to  100°  Fahr.]. 
When  there  is  a  tendency  to  diarrhoea,  it  should  be  given  hot. 
The  use  of  the  mineral  water  should  be  continued  for  several 
months.  Warm  abdominal  poultices  should  be  worn  during 
the  day  and  the  Priessnitz  compresses  at  night,  as  in  enteritis. 

2.  The  above-mentioned  foods  of  a  flatuous  nature  should 
be  strictly  forbidden,  while  the  following  are  recommended: 
white  bread,  stale  whole- wheat  bread,  meats  (excepting 
goose,  duck,  fat  pork,  and  ham),  fresh  eggs,  spinach,  cauli- 
flower, asparagus,  carrots,  peas,  rice,  sago,  noodles,  macaroni, 
butter,  baked  potatoes  (one  or  two  tablespoonfuls),  tea, 
weak  coffee,  cereal  soups,  red  wine,  sweet  fruit-sauces,  espe- 
cially apple  sauce,  marmalades  and  lemonade. 

Potatoes  and  milk  should  be  allowed  only  in  small 
quantities. 

3.  Carminative  remedies  which  relax  the  spasm  of  the 
colon  are  always  indicated.  Belladonna  and  menthol  in  the 
following  prescriptions  are  the  most  effective: 

1.  I^     Menthol,  gr.  xlv  3.0 

Extracti  belladonnse  foliorum,  gr.  ivss     0.3 
M.  ft.  pil.  No.  XXX.      Sig.--One  pill,  t.i.d. 

2.  I^     Extracti  belladonnse  foliorum,  gr.  ii         0.15 

Tannocol,  5iiss  10.0 

Sig. — -One  small  knifepoint,  t.i.d. 

3.  I^     Tincturse  belladonnas  foliorum,  5iiss      10.0 

Tincturse  valerianse,  ov  20.0 

M.  Sig. — Twenty-five  drops  in  a  cup  of  hot 
peppermint  tea,  t.i.d. 


270  DISEASES  OF  THE  DIGESTIVE  CANAL 

In  mild  cases,  the  following  carminatives  are  sufficient: 

1.  I)     Valerian, 

Peppermint, 
Fennel, 

Caraway,  aa,  5vi     25.0 
M.  Sig. — One  tablespoonful  to  a  cup  of  hot 
water,  morning  and  evening. 

Eight  or  ten  drops  of  the  tincture  of  belladonna  may 
be  taken  with  the  above. 

CLINICAL    CASES 

1.  Catarrh  of  the  Stnall  fntestine 
Case  1. — Geo.  B.,  an  officer  19  years  old,  had  had  an  attack  of  diar- 
rhoea six  or  seven  weeks  previous,  at  which  time  he  was  jaundiced  for  two 
weeks,  since  when  he  has  suffered  from  distention  and  a  feeling  of  fulness 
around  the  umbilicus,  which  was  especially  troublesome  in  the  morning, 
and  was  relieved  by  the  escape  of  gas,  which  was  sometimes  painful.  The 
appetite  was  poor.  He  defecated  a  soft,  sausage-like  stool  once  daily.  In 
the  evening  the  patient  was  often  troubled  by  borborygmus  and  gnawing 
pains  in  the  abdomen.  All  the  above  symptoms  were  increased  after  eating 
such  foods  as  cabbage,  baked  potatoes,  bread,  etc.  The  patient  was  pale 
and  emaciated.  The  liver  was  enlarged  and  the  umbilical  region  was  sen- 
sitive to  pressure.  After  treatment  with  Carlsbad  sprudel  salts,  a  non- 
irritating  diet  and  menthol  combined  with  calumba,  the  patient  made  rapid 
improvement. 

2.  Enterocolitis 

Case  1. — Wm.  F.,  a  stone-mason  50  years  old,  had  suffered  for  many 
5^ears  from  profuse  diarrhoea,  jDressure  in  the  stomach  after  eating  hard 
foods,  and  griping  pains  in  the  epigastric  region.  The  test-breakfast  was 
achylic, — total  acidity  being  6.  The  stools  were  of  fluid  consistency  and 
contained  much  mucus.  Improvement  followed  rest  in  bed,  the  use  of  hot 
poultices,  a  constipating  diet,  and  the  internal  administration  of  belladonna, 
tannocol,  hot  teas,  Rakoczy  water  and  hydrochloric  acid.  Whenever  the 
patient  returned  to  his  occupation,  at  which  he  worked  half-naked,  there 
was  always  a  relapse. 

Case  2. — Bertha  L.,  38  years  old,  had  for  four  or  five  years  suffered 
from  pressure  in  the  stomach  after  eating  hard  foods,  and  for  two  or  three 
years  from  diarrhoea.  She  had  four  or  five  stools  daily,  especially  after 
taking  flatuous  foods  and  cold  drinks.  There  was  a  catarrhal  condition  of 
both  apices.  The  stomach  was  completely  achylic,  and  the  stools  contained 
much  mucus.  The  patient  was  much  improved  by  a  constipating-diet  and 
tannocol,  which  was  continued  for  about  six  years. 


DISEASES  OF  THE  INTESTINE  271 

Case  3. — Emil  R.,  a  coachman  41  years  old,  had  for  two  months 
suffered  from  pressure  in  the  stomach  after  eating  hard  foods;  and  from 
gnawing  sensations  in  the  abdomen,  and  diarrhoea,  after  the  use  of  flatuous 
foods.  The  total  acidity  of  the  test-meal  was  8.  After  he  was  put  on  a 
constipating-diet,  with  hydrochloric  acid,  and  Rakoczy  water,  all  the  symp- 
toms disappeared.  The  rapid  improvement  in  this  case  was  due  to  the  fact 
that  it  was  of  relatively  short  standing. 

The  above  three  cases  were  associated  with  achylia  gastrica. 
The  following  are  cases  with  hyperchlorhyclria  and  acid  gastritis. 

Case  4. — Carl  K.,  a  druggist  40  years  old,  had  drunk  a  great  deal  of 
beer  when  a  student  at  the  university,  since  which  time  there  had  been  a 
tendency  toward  diarrhoea  and  vomiting.  For  one  year,  the  patient  had 
suffered  from  pyrosis  earlj'-  in  the  morning,  and  also  from  vomiting,  cramp- 
like pain,  and  diarrhoea.  The  stools  had  been  of  a  semi-solid  consistency 
for  several  years,  and  of  a  liquid  consistency  for  the  past  year.  The  bowels 
moved  from  one  to  three  times  a  day  and  the  fseces  were  admixed  with  mucus, 
especially  after  the  use  of  milk.  The  patient  was  not  emaciated,  since  his 
appetite  was  good,  and  he  ate  heartily.  The  total  acidity  of  the  Boas- 
Ewald  test -breakfast  was  70.  The  physical  examination  was  negative.  Treat- 
ment consisted  of  small  doses  of  hot  Vichy  water,  and  the  use  of  tannocol. 
The  patient  was  permanently  cured. 

Case  5. — Siegmund  T.,  a  merchant  45  years  old,  stated  that  he  had 
been  nervous  for  four  or  five  years,  and  had  suffered  every  three  or  four 
months  from  burning  sensations  in  the  stomach  and  griping  pain  in  the 
epigastrium  (flatulent  colic)  for  two  or  three  weeks  at  a  time.  The  stools 
were  unformed  and  of  a  semi-solid  consistency,  or  when  formed  were  the 
size  of  the  little  finger  and  made  up  of  short,  sponge-like  nodules  of  fecal 
matter,  which  the  patient  thought  usually  resulted  from  errors  in  diet  and 
excessive  smoking.  At  these  times  the  patient  was  very  nervous,  and  had 
a  frequent  desire  to  go  to  stool,  but  without  results.  After  escape  of  gas 
from  the  intestine,  the  patient  was  always  relieved  of  distress.  Treatment 
at  Carlsbad  resulted  in  a  cure. 

Owing  to  the  innumerable  variations  in  the  clinical 
history  of  chronic  enterocolitis,  it  is  impossible  to  introduce 
clinical  cases  illustrating  the  different  types  of  the  disease. 

Ulceration  of  the  Mucous  Membrane  of   the  Intestine 

Ulcers  of  every  form  and  extent, — varying  from  erosions 
no  larger  than  a  pin-heacl  to  deep  ulcers  the  size  of  a  dollar, — 
may  occur  anywhere  in  the  intestinal  tract,  from  the  duo- 
denum to  the  anus. 


272  DISEASES  OF  THE  DIGESTIVE  CANAL 

Etiology. — The  etiology  is  widely  diversified,  there 
being  peptic,  catarrhal,  decubital,  toxic,  embolic,  iiraniiic, 
and  malignant  and  infectious  ulcers, — such  as  tubercular, 
sj'philitic,  typhoid,  d3^sentcric,  etc. 

Peptic  ulcers  are  found  in  the  duodenum,  and  after  gastro- 
enterostomy, in  the  jejunum.     (See  chapter  on  Gastric  Ulcer.) 

Catarrhal  ulcers  result  from  an  increase  in  the  severity 
of  an  inflammator)^  process  of  the  mucosa,  just  as  erosions 
and  small  ulcers  of  the  gastric  mucosa  occur  in  acid  gastritis. 

Decubital  ulcers  arise  from  pressure  of  hard  scybala, 
especiall}^  in  the  csecum  and  in  the  hepatic  and  sigmoid  flex- 
ures of  the  colon;  also  from  pressure  of  neighboring  organs, 
such  as  the  uterus  and  gall-bladder,  and  from  traumata. 

Tubercular  ulceration  may  involve  the  entire  ileum  and 
colon;  and  it  seems  to  select,  by  preference,  the  csecal  region, 
where  irregular  tumors  resembling  neoplasms  are  found. 

Diagnosis. — The  diagnosis  is  usually  made  from  the 
following  symptoms,  which  I  quote  from  Nothnagel:  "Ulcer- 
ation of  the  intestine  often  runs  a  course  without  symptoms. 
Even  when  a  number  are  present,  or  when  the  ulcer  is  very 
large,  the  clinical  symptoms  are  frequently  not  at  all  propor- 
tionate to  the  intensity  of  the  anatomical  changes.  Signifi- 
cant signs  ....  only  are  pus  and  fibrous  tissue  in  the 
stools.  A  very  important  objective  sign,  also,  is  the  presence 
of  blood  in  the  stool,  although  this  must  be  interpreted  with 
great  caution.  On  the  other  hand,  the  number  of  stools 
passed,  or  the  fact  that  they  are  of  liquid  consistency,  will  not 
aid  in  forming  any  direct  conclusions  as  to  the  condition 
present." 

As  a  general  thing,  the  physician  should  suspect  intes- 
tinal ulceration  if  more  than  six  or  eight  stools  are  passed  in 
the  twenty-four  hours,  and  especially  if  the  patient  is  suffer- 
ing from  tuberculosis  of  the  lungs. 

[This  statement  does  not  apply  to  ulceration  of  the 
duodenum,  since  constipation  is  often  an  early  symptom  in 
this  condition,  being  indeed  the  symptom  for  which  the  patient 
frequently  consults  the  physician. 


DISEASES  OF  THE  INTESTINE 


273 


Further  attention  should  be  given  to  the  symptomatology 
of  duodenal  ulcer.  The  most  frequent  symptoms,  according 
to  Graham,*  are  pain,  gas,  vomiting,  hyperacidity,  hemor- 
rhage, general  weakness  and  nervous  irritability.  The  pres- 
ence of  this  combination  of  symptoms  should  always  suggest 
the  possibility  of  the  presence  of  duodenal  ulcer. 


Fig.  43. 


Ulcer  of  the  duodenum.    [Courtesy  of  Dr.  Stanley  P.  Black,  Hendryx  Laboratory,  University 

of  Southern  California. 

In  the  differential  diagnosis,  gall-bladder  disease  and 
peptic  ulcer  are  most  likely  to  lead  to  diagnostic  confusion, 
for  the  reason  that  the  symptoms  of  these  affections  so  nearly 
parallel  those  of  duodenal  ulcer  that  the  disease  is  most 
difficult  of  recognition. 

In  a  general  way,  it  may  be  said  that  the  symptoms  of 
duodenal  ulcer  simulate  those  of  gastric  ulcer  very  closely, — 
the  pain  being  largely  dependent  upon  food  and  occurring  from 

*  [The  Journal  of  the  American  Medical  Association,  February  9,  1907.] 
18 


274  DISEASES  OF  THE  DIGESTIVE  CANAL 

two  to  five  hours  after  meals,  and  being  relieved  temporarily  by 
food,  vomiting,  bicarbonate  of  soda,  or  anything  that  neutral- 
izes or  removes  the  acid-acrid  chyme  from  the  ulcer-area. 

Vomiting  is  less  common  in  duodenal  ulcer  than  in  gastric 
ulcer,  although  when  present  it  occurs  most  commonly  from 
two  to  five  hours  after  meals.  It  does  not  so  frecjuently  pro- 
duce cessation  of  pain  as  in  gastric  ulcer. 

Gas  is  a  distressing  sj^mptom  of  duodenal  ulcer.  This 
symptom  also  is  most  marked  from  two  to  five  hours  after 
meals,  and  is  relieved  by  the  same  factors  that  cause  cessa- 
tion of  the  pain. 

The  stomach-analysis  furnishes  about  the  same  findings 
as  does  the  gastric  juice  in  ulcer  of  the  stomach. 

For  the  differential  diagnosis  between  duodenal  ulcera- 
tion and  gall-bladder  disease,  see  editorial  note,   page   231.] 

The  physician  should  examine  the  stool  microscopically 
or  chemically  for  the  presence  of  blood.  It  is  necessary, 
before  performing  the  test  for  occult  blood,  to  place  the 
patient  on  a  meat-free  diet  for  two  or  three  days,  so  that  there 
can  be  no  ha?moglobin  introduced  in  the  food,  which  might 
give  rise  to  confusion  in  the  diagnosis.  I  have  found  the 
aloin  and  benzidin  tests  for  occult  blood  the  most  reliable 
(seepages  41  and  252). 

If  either  of  these  tests  gives  a  positive  reaction,  and 
gastric  ulcei'  is  excluded  from  the  diagnosis,  ulceration  of 
the  intestine  may  be  considered  as  cjuite  probable. 

For  the  macroscopical  and  microscopical  examination  of 
the  intestinal  contents,  the  physician  should  spread  out  the 
entire  stool  over  a  black  plate  and  examine  its  different  parts 
with  a  magnifying  glass  for  any  small  substances  of  a  grayish 
or  reddish  color,  the  examination  of  which  will  often  reveal 
large  numbers  of  leucocytes  and  tubercular  bacilli. 

Pain,  in  ulceration  of  the  intestine,  may  be  entirely  absent, 
and  there  is  less  mucus  than  in  simple  enteritis. 

If  ulceration  is  associated  with  enterocolitis,  involving  a 
greater  part  of  the  intestinal  mucosa,  there  will  be  severe 
diarrhoea,  amounting  to  as  many  as  twenty  stools  in  24  hours. 


DISEASES  OF  THE  INTESTINE  275 

Prognosis. — The  prognosis  depends,  naturally,  upon  the 
primary  disease,  and  as  a  general  rule,  is  not  absolutely  bad, 
since  even  in  tubercular  ulceration  a  clinical  cure  is  often 
obtained, — frequently  leaving,  however,  stenosis  of  the  bowel 
at  the  scar  of  the  ulcer. 

Treatment. — The  therapy  is  largely  symptomatic.  The 
diet  should  be  the  same  as  in  the  most  severe  forms  of  enter- 
itis,— consisting,  therefore,  of  cocoa,  chocolate,  rice,  grits, 
blackberry  wine,  blueberry  extract,  cereal  soups,  etc. 

Medicinally,  1.0  gram  [gr.  xv]  of  dermatol,  three  times 
daily;  tannocol  1.0  to  3.0  grams  [gr.  xv  to  xlv],  three  times 
daily;  bismuth  subnitrate  1.0  gram  [gr.  xv],  four  times 
daily;  bismutose  ^  teaspoonful,  or  calcium  carbonate  and  cal- 
cium phosphate,  equal  parts,  1  teaspoonful  three  times  daily. 

Mechanical  Treatment. — The  bowels  should  be  irrigated 
with  J  to  1  htre  of  the  following  solutions  at  body-temperature: 
silver  nitrate,  0.2  to  0.3  [gr.  iii-ivss]  to  1000;  salicylic  acid 
1 :  300;  or  thymol  1 :  1000;  or  an  enema  consisting  of  a  teaspoon- 
ful of  tannin  and  a  tablespoonful  of  starch  in  one  litre  of  water. 

Opium  is  indicated  for  the  amehoration  of  pain  and  its 
styptic  action,  especially  in  cases  offering  a  poor  prognosis.  I 
give  0.06  [gr.  i]  of  the  extract  three  times  a  day  in  pills.  Bella- 
donna may  be  used  for  the  relief  of  the  same  symptoms,  prefer- 
ably the  extract,  0.02  [gr.  |]  or  the  tincture,  three  times  daily. 

Codeine  or  heroine  may  be  substituted  for  either  of  the 
above-mentioned  drugs. 

For  severe  cases,  rest  in  bed  and  warm  compresses  are 
indicated.  With  cases  in  which  a  fatal  termination  seems 
imminent,  it  may  be  necessary  to  resort  to  surgery  to  produce 
an  artificial  anus  in  the  ascending  colon,  in  order  to  relieve 
the  colon  of  all  its  functions. 

Typhlitis  and  Appendicitis 

Typhhtis  and  appendicitis  are  specific  forms  of  inflamma- 
tion and  ulceration  of  the  intestine,  influenced  by  special 
anatomical  conditions.  We  cannot  discuss  the  pathological 
anatomy  of  the  subject  at  this  place. 


276  DISEASES  OF  THE  DIGESTIVE  CANAL 

From  the  clinical  standpoint,  it  is  first  of  all  desirable  to 
differentiate  typhlitis  stercoralis  from  appendicitis,  and  to 
classify  the  latter  into  the  catarrhal,  the  purulent,  and  the 
perforative-gangrenous  forms  of  appendicitis. 

Etiology. — The  most  frequent  causes  of  the  above  affec- 
tions are  acute  and  chronic  enteritis,  in  which  the  caecum  and 
appendix  are  implicated  and  become  filled  with  fluid  fa?ces, 
a  portion  of  which  remains  in  the  narrow  lumen  of  the 
appendix,  and  leads  to  the  formation  of  concrements,  or  to 
ulceration  and  stenosis,  which  in  their  turn  cause  dilatation, 
empyema,  perforation,  or  gangrene  of  the  organ. 

Symptomatology. — The  symptoms  are  so  well  known 
that  their  description  may  be  omitted  from  a  book  de- 
signed for  physicians  in  general  practice. 

Diagnosis. — In  making  a  diagnosis  of  appendicitis,  the 
following  four  symptoms  are  the  most  significant:  a,  pain; 
h,  tumor;   c,  fever;   d,  condition  of  the  bowels. 

Differential  Diagnostic  Points. — From  the  clinical  stand- 
point, the  physician  should  always  decide  upon  two  questions : 

1.  Does  typhlitis  stercoralis — or  appendicitis — exist? 

2.  Is    the     affection     a    severe     form,     which    requires 

operation? 

In  a  case  of  appendicitis  where  an  operation  is  indicated, 
it  is  vital  to  recovery  that  the  operation  be  not  postponed 
too  long;  while  it  is  equally  important  to  remember  that  in 
simple  typhlitis  no  operation  should  be  performed  at  all. 
It  is  well  known  that,  owing  to  the  surgical  tendencies  of  the 
present  time,  the  contrary  has  been  done  from  what  has  just 
been  stated  as  indicated, — which  error  has  aroused  consider- 
able prejudice  in  the  minds  of  the  laity  against  operative 
procedures  for  the  relief  of  appendicitis. 

The  differential  diagnosis  is  often  very  difficult.  On 
this  point.  Boas  remarks,  ''The  diagnosis  of  typhlitis  sterco- 
ralis, and  its  differentiation  from  appendicitis,  must  be  made 
only  with  the  greatest  reserve,  on  account  of  the  present 
status  of  our  knowledge. " 


DISEASES  OF  THE  INTESTINE  277 

The  following  diagnostic  points  have  generally  proven 
practical  and  reliable  for  me. 

1.    Typhlitis  Stercoralis  Acuta 

a.  Pain. — The  pain  is  of  a  dull,  stabbing  or  stinging 
character,  and  seldom  colicky.  Its  location  is  apparently 
superficial,  and  it  extends  upward  along  the  ascending  colon. 
It  is  considerably  relieved  by  the  apphcation  of  hot  com- 
presses, by  movement  of  the  bowels,  or  by  the  escape  of 
flatus.  The  skin-area  overlying  the  affected  region  is  more 
sensitive  to  pinching  than  to  deep  pressure. 

b.  Tumor. — The  tumor  is  usually  sausage-shaped,  corre- 
sponding to  the  caecum  or  colon;  in  case  diarrhoea  is  present, 
however,  no  tumor  is  palpable,  and  only  a  gurgling  murmur 
is  heard  in  the  right  iliac  fossa. 

c.  Fever.— A  febrile  reaction  is  either  entirely  absent,  or 
quite  mild,  corresponding  to  the  temperature  of  a  co-existing 
enteritis,  and  being  about  the  same  as  is  found  in  summer 
diarrhcBa. 

d.  The  Condition  of  the  Bowels. — The  bowels  are  rarely 
constipated.  In  typhlitis,  diarrhoea, — which  is  rare  in  appen- 
dicitis,— is  almost  always  present,  although  there  are  frequent 
exceptions  to  this. 

2.   Typhlitis  Stercoralis  Chronica 

(Pseudo-appendicitis) 

a.  Pain. — The  pain  in  chronic  typhlitis  is  of  variable 
intensity,  and  may  continue  for  years.  Pressure  and  tension 
are  rarely  severe;  they  are  more  often  located  behind  than 
at  McBurney's  point,  and  are  reheved  by  rest  in  bed,  hot 
compresses,  the  escape  of  gas,  and  gentle  upward  stroking. 

h.  Tumor. — A  sausage-shaped  tumor  may  be  palpated 
when  the  bowels  are  constipated. 

c.  Fever. — Fever  is  absent. 

d.  Condition  of  the  Bowels. — The  bowel-movements  are 
alternately  constipated  and  diarrhoeic.  There  is  much  flatu- 
lence, the  increase  of  which  aggravates  the  pain. 


278  DISEASES  OF  THE  DIGESTIVE  CANAL 

3.    Catarrhal  Appendicitis 

a.  Pain. — The  pain  in  catarrhal  appendicitis  is  intense 
and  of  a  cutting  or  boring  character,  radiating  in  all  direc- 
tions. It  is  increased  b}^  pressure  over  McBurney's  point,  or 
by  hot  applications,  but  is  relieved  by  the  ice-bag. 

b.  Tumor. — A  tumor  is  usualh'  present  about  as  large 
as  the  fist,  but  it  varies  in  size,  and  is  extremely  painful. 

c.  Fever. — The  temperature  is  generally  very  high,  being 
rarely  lower  than  40°  C.  [104°  F.],  but  a  chill  is  commonly 
an  early  symptom. 

d.  Condition  of  the  Boivels. — There  is  usually  constipation. 

4.   Suppurative  and  Gangrenous  Appendicitis 

a.  Pain. — The  pain  in  this  form  of  appendicitis  is  very 
severe,  resembling  that  of  peritonitis.  It  radiates,  and  is 
generall}'  of  a  tearing  quality,  relieved  by  the  ice-bag,  but 
intensified  by  hot  apphcations. 

6.  Tumor. — A  tumor  as  large  as  the  fist  is  usually 
present,  which  increases  rapidly  in  size,  and  is  very  painful 
to  pressure. 

c.  Fever. — The  disease  is  often  ushered  in  with  a  chill. 
The  temperature  is  extremely  high,  reaching  to  40°  C.  [104°  F.] 
and  more. 

d.  The  bowels  are  usually  constipated. 

5.    Appendicitis  Larvata  of  Ewald 

a.  Pain. — The  pain  is  indefinite,  and  is  often  entirely 
absent  in  the  ileocsecal  region. 

h.  Tumor. — No  tumor  is  present.  The  appendix  is  often 
thickened,  palpable,  and  sensitive  to  pressure,  especially 
during  an  acute  exacerbation. 

c.  Fever. — There  is  no  fever. 

d.  Condition  of  the  Bowels. — There  is  periodical  diarrhoea. 

6.    Recurrent  Appendicitis 

a.  Pain. — The  pain  is  periodical,  continuing  for  months 
with  variable  intensity,  according  to  the  character  of  the 
chronic  appendicitis. 


DISEASES  OF  THE  INTESTINE  279 

b.  Tumor. — ^A  tumor  is  either  constantly  present, — 
diminishing  in  the  interval  between  attacks,  and  increasing 
again  during  a  recurrence, — or  it  may  be  entirely  absent. 

c.  Fever. — There   is    fever   is   nearly   all   cases. 

d.  Condition  of  the  Bowels. — The  bowels  are  generally 
sluggish. 

Summary. — Diarrhoea,  and  also  constipation,  when  fever 
is  absent,  are  generally  indicative  of  typhlitis.  Constipa- 
tion with  high  fever  is  indicative  of  appendicitis,  as  is  also 
constipation  with  or  without  fever  when  a  tumor  is  present, — 
as  extracsecal  tumors  and  also  high  fever  are  almost  always 
indicative  of  appendicitis.  Pain,  alone,  is  of  only  a  slight 
characteristic  value  in  the  differential  diagnosis. 

Treatment. — The  treatment  of  typhlitis  and  appendicitis 
simplex  should  be  conservative.  In  suppurative,  perforative, 
or  gangrenous  appendicitis,  it  should  be  operative  during  the 
attack.  In  appendicitis  larvata  and  in  recurrent  appendi- 
citis, when  the  symptoms  are  annoying  and  attacks  frequent, 
surgical  treatment  should  be  given  in  the  interval. 

A.      CONSERVATIVE    THERAPY 

Diet. — Only  fluids  should  be  allowed,  such  as  tea,  milk, 
cocoa,  cream,  broths,  oatmeal  gruel,  and  wine  with  the 
yolks  of  eggs. 

Medicinal. — Of  the  extract  of  belladonna  0.02  to  0.03 
[h~i  gi"-]  should  be  given  three  or  four  times  daily;  or 
if  there  is  a  tendency  to  vomiting,  double  this  quantity  should 
be  given  per  rectum.  If  pain  is  very  severe,  0.06  to  0.1 
[gr.  i  to  iss]  of  the  extract  of  opium,  or  15  to  20  drops  of  the 
tincture,  should  be  given  three  or  four  times  a  day. 

If  there  is  diarrhoea  without  fever,  the  various  styptics 
are  indicated,  for  instance,  tannocol;  if  with  fever,  a  mixture 
of  muriatic  acid. 

For  constipation,  oil  enemata  are  prescribed. 

In  case  of  high  fever,  ice-bags  should  be  apphed  exter- 
nally; with  moderate  fever— 38°  to  39°  C.  [100.4  to  102.2  F.]— 
the    Priessnitz    compresses.      In    the    absence    of    fever,    hot 


280  DISEASES  OF  THE  DIGESTIVE  CANAL 

poultices,  thcniial  coils,  etc.,  should  be  used.  In  chronic 
appendicitis  or  typhlitis,  the  mud-baths  or  the  niud-i)oultices, 
such  as  are  given  at  Franzensbad,  are  useful. 

B.    SURGICAL    TREATMENT 

Under  this  heading,  naturally,  only  the  indications  for 
surgical  intervention  will  be  spoken  of.  Operation  should  be 
performed  immediately  in  young  persons  when  the  attacks 
begin  with  fever  of  39°  C.  [102.2°  F.]  or  more.  With  older 
patients,  it  is  preferable  to  wait  one  or  two  days  before  operat- 
ing, because  in  these  cases  adhesions  usually  exist  which 
prevent  the  rapid  spread  of  pus.  If  purulent  appendicitis 
has  already  given  rise  to  peritonitis  or  a  subphrenic  abscess, 
operative  procedures  are  usually  without  avail. 

C.    DIFFERENTIAL    DIAGNOSIS 

In  the  differential  diagnosis,  it  is  only  necessary  to 
mention  that  certain  other  pathological  conditions  need  to  be 
thought  of,  especially  invaginatio  ileocolica,  neoplasms,  renal 
colic,  incomplete  inguinal  hernia,  pyosalpinx,  and  other 
right-sided  diseases  of  the  adnexa,  [gall-bladder  diseases],  etc. 

CLINICAL    CASES 

A  cute  and  Chronic  Typhlitis 

Case  1. — Rosa  E.,  32  years  old,  had  suffered  from  colic  two  weeks 
previous,  after  partaking  freely  of  pears  and  beer.  There  was  a  boring  pain 
in  the  csecal  region,  and  constipation,  but  no  fever.  Treatment  consisted 
of  the  application  of  thermal  coils,  hot  compresses,  rest  in  bed,  belladonna, 
and  oil-enemata, — after  which  the  patient  gradually  improved.  Later, 
however,  there  was  a  recurrence  of  the  trouble,  following  errors  in  diet. 

Case  2. — Mrs.  H.,  23  years  old,  had  suffered  for  years  from  constipation 
associated  with  colic.  For  several  weeks  she  had  complained  of  dull  pressure 
in  the  ileocsecal  region,  and  for  the  past  five  days  had  suffered  from  colicky 
pains  in  the  right  iliac  fossa.  She  was  constipated.  A  fecal  tumor  was  jDal- 
pable.  There  was  sensitiveness  to  pressure,  but  no  fever.  Recovery  occurred 
after  rest  in  bed  for  eight  days  and  the  use  of  hot  applications  to  the  abdomen. 

Case  3. — Gustav  L.,  a  merchant  40  years  old,  had  for  one  or  two 
years  suffered  frequently  from  pain  in  appendix  region,  especially  when 
obliged  to  stand  for  a  long  time.  Temporary  rest  in  bed  always  produced 
improvement.  Later,  an  inguinal  hernia  developed ;  and  after  the  application 
of  a  suitable  hernia-truss,  all  evidences  of  the  "appendix  pains"  disappeared. 


DISEASES  OF  THE  INTESTINE  281 

Tumors  and  Neoplasms  of  the  Intestine 

If  we  except  tumors  of  the  rectum, — which  will  be  con- 
sidered separately, — neoplasms  of  the  intestinal  canal  are  com- 
paratively infrequent.  According  to  Von  Leube,  80  per  cent,  of 
intestinal  carcinomata  are  located  in  the  rectum;  15  per  cent.,  in 
the  caecum  and  colon;  and  only  5  per  cent.,  in  the  small  intestine. 

Diagnosis. — ^The  lower  the  location  of  a  tumor  in  the 
intestinal  canal,  the  greater  is  the  possibility  of  an  early  diag- 
nosis. A  carcinoma  of  the  ascending  colon  produces  obstruc- 
tion-phenomena much  later  than  does  a  tumor  of  the  sigmoid 
flexure;  because,  for  instance,  in  the  former  case  the  intestinal 
contents  are  of  a  fluid  consistency  and  therefore  have  less 
difficulty  in  passing  the  obstruction.  The  diagnosis  is  easily 
made  from  the  following  symptoms: 

1.  Cachexia  and  the  other  general  symptoms  of  cancer, 
which  cannot  be  accounted  for  by  a  carcinoma  of  the  stomach, 
rectum,  or  other  organ,  may  naturally  suggest  malignant 
disease  of  the  intestine. 

2.  Pain. — If  there  is  no  stenosis,  there  are  only  indefinite 
painful  sensations  in  the  abdomen.  If,  on  the  other  hand, 
stenosis  of  the  intestine  is  present,  there  is  intense  pain  of  a 
colicky,  contracting  character,  particularly  if  the  tumor  is 
located  in  the  splenic  flexure  of  the  colon. 

3.  Constipation  or  Pseudodiarrhcea. — If  the  latter  occurs, 
the  patient  must  often  go  to  stool  from  6  to  10  times  daily. 
Generally,  nothing  passes  from  the  bowels  but  mucus,  which 
may  be  mixed  with  blood  and  pus;  and  the  stools  if  formed 
have  a  caliber  about  that  of  a  lead  pencil. 

4.  Intestinal  Hemorrhage. — Hemorrhage,  which  is  either 
microscopically  or  macroscopically  demonstrable,  occurring 
in  a  patient  who  has  never  had  any  previous  intestinal  trouble, 
— if  hemorrhoids,  etc.,  can  be  excluded, — is  very  suggestive 
of  a  malignant  disease  of  the  intestine. 

5.  Intestinal  "Stiffening." — Intestinal  ''stiffening,"  that  is, 
a  visible  peristaltic  contraction  of  the  colon  above  its  narrowed 
portion,  most  freciuently  occurs  in  the  transverse  colon. 


282  DISEASES  OF  THE  DIGESTIVE  CANAL 

G.  Tumor. — Tumors  of  the  intestine  arc  usually  movable. 
They  are  palpable  only  relatively  late,  when  the  patient 
becomes  cachectic  and  the  abdominal  walls  relaxed.  In  entcr- 
optotic  individuals,  or  those  with  pendulous  abdomen,  a 
tumor  is  palpable  considerably  earlier  than  otherwise.  Mahg- 
nant  neoplasms  are  hard  and  irregular  in  shape. 

Differential  Diagnosis.— The  differential  diagnosis  is  some- 
times very  hard  to  make,  since  we  must  exclude  tubercular 
and  stercoral  tumors  of  the  caecum,  scybala  in  the  sigmoid 
flexure  and  the  transverse  colon,,  gall-stones,  neoplasms  of 
the  stomach,  tumors  of  the  gall-bladder  or  pancreas,  retro- 
peritoneal cysts,  carcinomata  and  echinococcic  cysts  of  the 
kidnej^s,  movable  kidney  or  spleen,  foreign  bodies,  etc. 

Treatment. — The  treatment  is  of  a  surgical  nature,  and 
operation  should  be  resorted  to  as  early  as  possible.  In  the 
event  that  the  patient  refuses  operation,  the  treatment  must 
become  symptomatic, — care  being  taken  to  produce  stools  of 
soft  consistency  by  the  use  of  castor  oil,  Carlsbad  salts,  or 
rhubarb,  every  two  or  three  days;  or  by  oil  enemata,  contain- 
ing I  litre,  to  be  given  every  second  or  third  day. 

Diet. — The  diet  should  be  such  as  will  furnish  as  httle 
intestinal  debris  as  possible,  and  should  consist  of  milk,  cream, 
butter,  cereal  soups  and  gruels,  eggs,  tender  meats,  fish, 
broths,   stewed   fruits,    fruit-juice,   honey,   etc. 

In  private  practice,  some  of  the  artificial  food-prepara- 
tions may  be  used  to  great  advantage,— such  as  somatose, 
roborat,  puro,  eucasin,  sanatogen,  etc. 

Medicinal  Treatment. — Medicinal  treatment  is  indicated 
for  the  reHef  of  coUcky  pain;  0.02  of  the  extract  of  bella- 
donna, when  given  three  times  daily,  is  one  of  the  most 
suitable  medicaments  for  this  purpose.  If  preferred,  0.05 
of  the  extract  may  be  given  three  times  daily,  per  rectum. 
The  use  of  opium  is  less  satisfactory  than  the  above. 

CLINICAL    CASE 
Case  1. — Carl  H.,  a  laborer  56  years  old,  had  for  about  six  months 
suffered  from  indefinite  pains  in  the  abdomen.     He  had  passed  from  12  to 
15  stools  daily,  of  a  chocolate  color  and  a  semi-solid  consistency,  which  often 


DISEASES  OF  THE  INTESTINE  283 

contained  brown  and  grayish-red  particles.  There  had  been  a  gradual 
aggravation  of  the  symptoms,  with  increasing  cachexia.  Physical  examina- 
tion was  negative,  except  that  there  was  some  blood  in  the  stools.  There 
was  no  tumor.  The  patient  was  cachectic.  He  grew  gradually  worse  and 
died.  An  extensive  ulcer  which  had  undergone  carcinomatous  degeneration 
was  foUnd  in  the  splenic  flexure  of  the  colon. 

Displacements  of  the  Intestine 

(Pendulous  Abdomen,  Hang-Belly,  etc.) 

A.    Congenital  Malpositions,  Anomalies,  etc. 

Apart  from  situs  inversus,  the  displacements  of  the  caecum, 
with  the  appendix  and  the  sigmoid  flexure, — in  consequence 
of  extraordinary  length  of  their  mesenteries, — are  of  special 
importance. 

Such  congenital  anatomical  conditions  account  for  appen- 
dicitis in  the  left  iliac  fossa  and  for  volvulus  of  the  sigmoid 
flexure.  The  caecum  has  been  found  in  the  hernial  sac  of  a 
congenital  scrotal  hernia;  and  as  a  curios'ity,  we  may  mention 
that  congenital  hernia  of  the  diaphragm  has  been  discovered 
at  autopsy,  when  the  stomach  was  found  in  the  thoracic  cavity. 

In  habitus  enteropticus,  which  has  already  been  discussed 
in  detail  in  the  section  on  Diseases  of  the  Stomach,  the  position 
of  the  transverse  colon  corresponds  to  the  abnormally  low 
position  of  the  greater  curvature  of  the  stomach,  and  gradually 
becomes  lower  with  the  age  of  the  patient.  The  transverse 
colon,  in  this  affection,  is  usually  found  at  the  umbilicus  or 
a  finger's  breadth  above  or  below  it. 

B.  Acquired  Displacements  of  the  Intestine 

1.  Total:     a,  constitutional;    h,  due  to  local  conditions. 

2.  Partial,  such  as  herniae,  tumors,  etc. 

1.   General  Enteroptosis 

a.  A  general  displacement  of  the  intestine  results  from 
a  congenital  habitus  enteropticus  if  the  abdominal  walls  have 
become  relaxed  following  pregnancy,  or  from  i-mpairment  of 
the  general  nutrition,  or  from  absorption  of  the  accumulations 
of  adipose  tissue  in  the  abdominal  cavity. 


284  DISEASES  OF  THE  DIGESTIVE  CANAL 

b.  Pendulous  abdomen  is  sometimes  present  without 
hahifus  entei'opticus  after  pregnancy;  or  when  rapid  emacia- 
tion has  occurred  in  a  previously  obese  person,  as  in  cases  of 
phthisis,  carcinoma,  etc. 

2.    Partial  Enteroptosis 

a.  Individual  portions  of  the  intestine  may  assume  an 
abnormally  low  position,  either  from  their  own  weight  or 
from  the  extra  weight  given  them  by  the  presence  of  tumors 
or  fecal  accumulations.  In  chronic  constipation,  or  in  relaxa- 
tion of  the  abdominal  w^alls,  the  colon  may  assume  the  shape 
of  a  capital  letter  '^M, " — the  middle  portion  of  the  transverse 
colon  standing  immediatel}^  above  the  symphj'-sis.  I  have 
seen  several  such  cases. 

b.  In  this  category  of  partial  displacements  of  the  intes- 
tine belong  external  hernia,  which,  however,  cannot  be 
properly  discussed  in  a  work  on  internal  medicine. 

Diagnosis. — Anomalous  positions  of  the  intestine,  as 
such,  usually  run  a  course  without  symptoms,  and  are  occas- 
ionally discovered  when  palpating  the  abdomen  of  a  patient 
suffering  from  other  affections.  Quite  frequently,  however, — 
as  a  result  of  such  displacements  of  the  intestinal  tube, — ileus 
arises,  whose  exact  diagnosis  is  generally  impossible.  It 
can  be  arrived  at  only  with  a  certain  degree  of  probability, 
because,  in  addition  to  internal  hernise,  there  is  an  unlimited 
number  of  other  affections  that  may  produce  ileus.  Only  the 
autopsy  in  vivo  or  post  mortem  explains  such  anatomical 
abnormalities. 

Treatment. — The  treatment  consists  chiefly  in  the  appli- 
cation of  suitable  abdominal  bandages,  supports,  and  abdom- 
inal corsets.  In  every  case  of  "hang-belly,"  when  there  are 
unpleasant  drawing  sensations  in  the  costal  arch  and  a  feeling 
of  fulness  in  the  abdomen,  especially  after  eating,  or  when 
the  patient  is  more  uncomfortable  in  a  horizontal  position, 
I  prescribe  such  abdominal  support. 

Achilles  Rose,  of  New  York,  has  recently  made  use  of 
the  appHcation  of  four  strips  of  adhesive  plaster,  8  to  9  cm. 


DISEASES  OF  THE  INTESTINE  28.5 

wide,  for  this  purpose.  The  first  strip,  about  4.5  cm.  hjng, 
extends  from  the  symphysis  to  the  sternum;  the  second  and 
third  strips,  .50  cm.  long,  are  applied  from  the  symphysis 
diagonally  around  the  left  and  the  right  thoracic  walls  to  the 
spinal  column;  the  fourth  strip  is  applied  across  the  abdomen 
above  the  symphysis  from  one  iliac  fossa  to  the  other.  The 
adhesive  plaster  may  be  worn  for  three  or  four  weeks,  when 
it  should  be  renewed,  to  prevent  disagreeable  perspiration, 
eczema,  etc., — especially  in  warm  weather.  [See  illustrations 
and  further  details,  page  194.] 

In  addition  to  the  above  means,  the  physician  should 
always  devise  treatment  which  will  strengthen  the  muscu- 
lature of  the  abdomen,  such  as  heavy  massage  of  the  abdominal 
muscles,  physical  culture,  and  gymnastic  exercises,  such  as 
raising  and  lowering  the  legs  or  trunk  of  the  body.  The  con- 
dition may  also  be  improved  by  a  course  of  forced  feeding, 
by  which  the  relaxed  condition  of  the  musculature  is  improved 
and  the  abdominal  space  is  made  smaller  by  the  deposition 
of  adipose  tissue. 

The  treatment  of  hernia  is  surgical. 

SECONDARY  ORGANIC  DISEASES  OF  THE  INTESTINE 

Stenosis  and  Dilatation  of  the  Intestinal  Canal 

(Not  Including  the  Rectum) 

General  Remarks. — Just  as  stenosis  of  the  pylorus  and 
dilatation  of  the  stomach  are  the  results  of  some  primary  or- 
ganic disease  of  the  stomach, — such  as  peptic  ulcer,  carci- 
noma, perigastritis,  etc.,— stenosis  and  dilatation  of  the  in- 
testinal canal  may  develop  more  or  less  quickly  from  similar 
primary  affections, — such  as  ulceration,  compression,  new 
growths,  adhesions,  etc. 

As  a  sequel  to  ulcer,  cicatricial  stenosis  results,  which  in 
turn  gives  rise  to  hypertrophy  and  dilatation  of  that  portion 
of  the  intestinal  tube  lying  just  above, — according  to  the 
general  law  of  compensatory  concentric  hypertrophy. 

Stenosis  of  the  intestine  is  a  chronic  affection;  although 
any   aggravating   cause, — such   as   the   lodging   of   hard    and 


286  DISEASES  OF  THE  DIGESTIVE  CANAL 

irritating  remnants  of  foods  or  the  inflammatory  swelling  of 
that,  portion  of  the  gut, — may  lead  to  the  acute  stage  of  total 
obstruction  of  the  intestine. 

Stenoses  of  the  duodenum  and  of  the  pylorus  have  been 
discussed  together  in  a  previous  chapter.  The  treatment  is 
practically  the  same  in  both  affections. 

Acute  dilatation  of  the  intestinal  canal  without  stenosis  re- 
sults from  paralysis  of  the  intestinal  musculature,  which  will  be 
considered  in  detail  in  the  chapter  on  Intestinal  Obstruction. 

Etiology. — The  stenotic  factors  are  as  follows: 

1.  Intestinal. — Neoplasms,  cicatrices  following  tubercular, 
syphilitic,  and  decubital  ulcers,  hard  scybala  lodged  in  the 
folds  of  the  intestine,  partial  volvulus,  moderate  invagination 
of  the  intestinal  tube,  or  incomplete  hernia. 

2.  Peritoneal. — The  congenital  and  acquired  formation  of 
adhesion-bands,  especially  following  trauma,  laparotomies, 
cholelithiasis,  peritonitis,  appendicitis,  and  perimetritis. 

3.  Neighboring  Orgaiis. — Compression  by  a  distended 
gall-bladder,  enlarged  lobe  of  the  liver,  echinococcic  cysts, 
retroverted  gravid  uterus,  abdominal  and  pelvic  tumors,  and 
especially  ovarian  cj'sts. 

Symptomatology. — A  stenosis,  especially  if  located  in 
the  small  intestine,  or  in  the  colon  as  low  as  the  hepatic  flex- 
ure, may  exist  for  quite  a  long  time  without  producing  any 
symptoms,  for  the  reason  that: 

1.  The  Hquid  faeces  of  these  portions  of  the  intestinal 
canal  may  pass  through  a  relatively  narrowed  portion. 

2.  H3^pertrophy  of  the  musculature  tends  to  overcome 
the  effect  of  the  obstruction,  since  the  former  increases  pro- 
portionately to  the  diminution  in  the  size  of  the  lumen  of 
the  intestine.  In  this  way,  even  a  stenosis  of  the  sigmoid 
flexure  may  be  compensated  for  quite  a  while,  until  some 
excessive  demand  suddenly  brings  about  a  compensatory 
disturbance,  and  thereby  introduces  the  evident  signs  and 
symptoms  of  intestinal  obstruction. 

The  first  subjective  symptoms  are  a  sluggish  condition 
of  the  bowels,  griping,  a  feehng  of  tension  in  the  abdomen, 


DISEASES  OF  THE  INTESTINE  287 

and  severe  recurrent  attacks  of  colic  which  disappear  for  two 
or  three  days  after  a  very  free  evacuation  of  the  bowels. 
Usually  the  patient  is  nauseated  and  has  a  tendency  to  vomit, 
besides  a  general  feeling  of  anxiety. 

Objectively,  the  physician  will  observe  that  the  stool  is 
of  small  caliber, — about  the  size  of  a  lead-pencil, — and  is 
made  up  of  broken,  irregular,  or  square  fragments  of  fecal 
matter.  Diarrhoea  is  sometimes  present  if  a  secondary  catarrh 
develops  above  the  stenosis,  which  causes  a  hquefaction  of 
the  stagnating  faeces. 

Another  very  important  objective  sign  is  the  so-called 
"stiffening"  of  the  intestine,  which  was  first  described  by 
Nothnagel,  and  consists  of  visible  and  palpable  tonic  con- 
tractions of  that  portion  of  the  intestine  above  the  stenosis. 

A  third  sign  is  meteorism. 

All  the  above-mentioned  symptoms  will  disappear  after 
a  free  evacuation  of  the  bowels. 

Diagnosis. — In  any  given  case,  the  following  points 
must  be  decided: 

1.  Does  a  stenosis  actually  exist? 

2.  What  is  its  location? 

3.  What  is  its  pathology? 

"Sometimes,"  says  Nothnagel,  "the  diagnosis  of  stenosis 
of  the  intestine  may  be  made  with  absolute  certainty,  and 
sometimes  this  is  simply  impossible;  between  these  extremes 
there  exists  a  large  number  of  cases  in  which  the  diagnosis  can 
be  made  with  greater  or  less  probability." 

1.  We  may  assume  the  occurrence  of  a  more  or  less 
rapid  narrowing  of  the  intestinal  lumen,  when  a  person  who 
has  formerly  had  normal  functions  of  the  bowels  begins  to 
suffer  from  constipation,  coHcky  pains  and  meteorism,  or 
when  intestinal  "stiffenings"  are  observed,  or  when  the  stool 
itself  is  of  small  cahber  and  composed  of  broken  fragments 
of  hard  fecal  matter. 

2.  If  "stiffenings"  of  the  colon  are  visible,  the  location 
of  the  stenosis  is  usually  in  the  region  of  the  sigmoid  flexure; 


288  DISEASES  OF  THE  DIGESTIVE  CANAL 

while  a  strong  peristalsis  of  the  small  intestine, — commonly 
observed  only  when  there  is  a  diastasis  of  the  recti  muscles 
or  relaxation  of  the  abdominal  walls, — usually  indicates  that 
the  lesion  is  in  the  ileocaccal  region. 

3.  Only  long  observation  will  make  clear  the  nature  of 
the  stenosis.  Blood  and  pus  in  the  stool,  as  well  as  the  pal- 
pabilit}'  of  a  tumor,  are  indicative  of  a  malignancy.  In  order 
to  diagnose  a  compression  stenosis,  it  is  necessary  to  make  an 
accurate  examination  of  all  the  neighboring  organs  of  the  abdo- 
men and  pelvis,  especially  the  rectum  and  the  female  genital 
organs.     (See  discussion  on  Palpation,  in  the  General  Section.) 

Differential  Diagnosis. — Practically  one  condition  only 
will  give  rise  to  confusion  in  the  diagnosis,  i.  e.,  spastic  consti- 
pation, when  hard  stools  of  small  caliber  are  passed,  associated 
with  colicky  pains.  The  following  points  will  assist  in  the 
differentiation  of  this  affection  from  stenosis  of  the  bowel : 

Preceding  spastic  constipation,  there  is  almost  always  a 
long  period  of  atonic  constipation.  In  spastic  constipation, 
the  stool  is  surrounded  by  membranous  mucus,  and  the  entire 
colon  is  palpable  as  a  sensitive,  hard,  band-hke  stricture  about 
the  size  of  the  little  finger.  After  suitable  diet  and  oil  enemata 
for  three  or  four  weeks,  there  is  usually  an  improvement. 
Sausage-shaped  stools  of  large  caliber  are  then  passed  without 
difficulty,  and  the  intestinal  "stiffenings"  entirely  disappear. 

Treatment. — The  internal  treatment  has  already  been 
detailed  in  the  chapter  on  Ulcer  of  the  Intestine.  The  diet 
should  be  as  free  as  possible  from  foods  leaving  a  heavy 
residue  in  the  intestine,  but  should  be  rich  in  butter  and  fats, 
and  should  contain  a  large  amount  of  stewed  fruit. 

Laxatives,  antispasmodic  remedies,  —  such  as  0.02  to 
0.03  [\-\  gr-]  of  the  extract  of  belladonna  per  mouth,  or  0.03 
to  0.05  [^-|  gr.]  per  rectum, — and  oil  enemata,  should  be 
administered. 

Frequent  and  repeated  attacks  are  an  indication  for 
surgical  treatment;  and  in  any  case  where  the  abdominal 
pathology  is  doubtful,  it  is  the  duty  of  the  physician  to  obtain 
the  opinion  of  an  experienced  surgeon. 


DISEASES  OF  THE  INTESTINE  289 

Recently,  the  use  of  thiosinamin  has  been  recommended 
in  cicatricial  stenosis  of  the  intestine;  ^  to  1  c.c.  of  the  fol- 
lowing solution  should  be  subcutaneously  injected  daily  in 
the  interscapular  region. 

I^     Thiosinamin,  3ii       8.0 

Glycerini,  oiii  12.0 

Alcohol  dil.,  5v       20.0 
M.  Sig. — To  be  used  by  the  physician. 

Whenever  syphilis  is  suspected,  sodium  iodide  should,  of 
course,  be  prescribed. 

Intestinal  Obstruction 

General  Remarks. — Ileus,  or  acute  intestinal  obstruction, 
above  all  other  diseases  of  the  intestine,  demands  a  wide  per- 
sonal experience  for  its  early  diagnosis,  and  for  the  selection 
of  the  proper  therapeutic  procedures.  One  of  the  most 
difficult  tasks  in  the  diagnosis  and  therapeutics  of  these 
conditions  is  to  decide,  in  a  given  case,  whether  a  purgative 
or  a  narcotic  should  be  prescribed,  whether  ice  or  hot  com- 
presses should  be  used,  and  whether  an  operation  is  indicated. 

In  any  case,  the  responsibihty  is  so  great  that  no  physician 
should  neglect  to  have  consultation  with  either  a  clinician  or 
a  surgeon  of  experience  as  early  as  possible,  in  order  that 
through  mutual  and  repeated  observations  the  developments 
of  the  case  may  be  carefully  followed  and  the  indications 
thoroughly  established  before  secondary  symptoms  have 
developed  which  might  cloud  the  picture  of  the  disease  in 
such  a  way  that  it  would  become  unrecognizable.  In  addition 
to  this,  it  is  always  best,  if  possible,  to  have  an  experienced 
nurse  in  constant  attendance  upon  the  case. 

Etiology. — Precisely  the  same  etiological  factors  as  lead  to 
stenosis  of  the  intestine  will  lead  also  to  the  gradual  aggravation 
of  stenosis  until  intestinal  obstruction  results.  The  importance 
of  the  subject  justifies  a  repetition  of  these  etiological  factors. 

The  most  frequent  causes  are  external  or  internal  herniae; 
malignant  or  benign  stenoses  of  the  intestinal  lumen;  volvulus 
and   acute   flexures   from  bands  of   omentum;    invagination, 

19 


290  DISEASES  OF  THE  DIGESTIVE  CANAL 

spasmodic  contracture  or  paralysis  of  the  intestinal  muscula- 
ture; and  the  compression  produced  by  a  pathological  con- 
dition of  some  neighboring  organ, — among  which  the  retro- 
flexion of  the  gravid  uterus  must  not  be  forgotten. 

The  subject  will  be  more  clearly  comprehended  after 
classifying  it  into  three  principal  groups  of  cases: 

1.  Ileus  resulting  from  mechanical  occlusion  of  the  bowel. 
2.  Compression  ileus.     3.  Strangulation  ileus. 

Symptomatology. — An  absolute  retention  of  faeces  and 
gases  develops  more  or  less  acutely;  while  nausea,  eructa- 
tions, meteorism,  singultus,  colicky  pains,  fecal  vomiting, 
cold  perspiration,  peritonitis,  fever  and  collapse  gradually 
appear;  in  short,  there  arises  the  well-known  clinical  picture 
of  miserere,  with  the  so-called  fades  Hippocraiica. 

Diagnosis. — Nothnagel,  in  speaking  of  intestinal  obstruc- 
tion, says,  "Even  the  most  expert  surgeon,  as  well  as  the 
most  experienced  internist,  must  acknowledge  that  every 
new  case  may  bring  with  it  unexpected  developments.  All 
care  in  the  examination,  all  diagnostic  discrimination,  and  even 
all  personal  experience,  will  frequently  leave  one  in  the  lurch. 
The  difficulties  in  such  cases  are  simply  insurmountable." 

Before  proceeding  with  an  analysis  of  a  concrete  case, 
two  points  should  be  carefully  considered: 

1.  The  hernial  rings,  the  rectum,  and  the  uterus  should 
be  carefully  palpated  in  order  to  determine:  whether  there  is 
a  possibly  existing  strangulation  hernia,  or  a  rectal  stricture 
which  has  previously  run  a  latent  clinical  course,  or  whether 
a  retrofiexed  gravid  uterus  is  giving  rise  to  the  symptoms. 

2.  Whether  there  is  an  accumulation  of  fseces  resulting 
from  spasmodic  contraction  or  paralysis  of  the  intestine, 
without  the  presence  of  an  anatomical  lesion. 

Spasm  of  the  intestinal  musculature  occurs  in  lead  colic, 
and  in  spastic  constipation,  which  has  been  mentioned  above 
and  will  be  described  in  detail  later  on;  and  it  also  occurs  in 
acute  coHtis  caused  by  the  lodgment  of  irritating  food-remnants, 
— such  as  cucumbers  or  pears  which  have  been  poorly  masti- 
cated,— in  the  folds  of  the  mucous  membrane  of  the  intestine. 


DISEASES  OF  THE  INTESTINE  291 

Such  patients  have,  as  a  rule,  suffered  for  a  long  period 
from  chronic  constipation.  The  internal  administration  of 
atropine  and  the  use  of  high  rectal  enemata  of  oil  will  gener- 
ally give  relief  in  these  cases. 

The  causes  of  paralysis  of  the  intestinal  musculature  are 
as  follows: 

Opium-poisoning;  peritoneal  shock  following  trauma  to  the  abdomen; 
laparotomy;  ruptured  tubal  pregnancy;  perforation  of  the  stomach  or 
intestine ;  the  same  causes  as  produce  peritonitis ;  and  finally,  chronic  atonic 
constipation. 

The  presence  of  fever  is  always  suggestive  of  peritonitis  as  a  cause  of 
paralysis  of  the  bowels;  and  especially  when  it  is  associated  with  persistent 
vomiting,  diffuse  pain  in  the  abdomen, — especially  when  vomiting, — and 
generalized  sensitiveness  to  pressure  over  the  abdomen.  These  symptoms 
are  significant  of  peritonitis  as  a  causal  factor,  even  if  fever  is  absent. 

If,  from  employment  of  the  above-mentioned  principles, 
the  physician  can  exclude,  as  etiological  factors, — hernial 
rings,  peritonitis,  affections  of  the  rectum  or  uterus,  and 
spasmodic  contraction  or  paralysis  of  the  intestinal  muscu- 
lature, he  may  then  naturally  assume  the  presence  of  an 
anatomical  obstruction,  the  exact  nature  of  which  will  fre- 
quently not  be  recognized  before  operation  or  autopsy. 

If  the  patient  has  been  under  observation  since  the 
beginning  of  the  illness,  the  location  of  the  trouble  can  usually 
be  established  with  a  fair  degree  of  success.  A  consideration 
of  the  following  symptoms  will  best  serve  to  diagnose  the 
position  of  the  lesion: 

1.  Pain. 

2.  Meteorism. 

3.  Vomiting. 

4.  The  effect  of  enemata. 

5.  Temperature. 

1.  Pain. — In  obstruction  of  the  colon,  there  is  a  fre- 
quently-recurring colic, — resembling  labor-pains, — of  from 
one  to  five  minutes'  duration,  which,  according  to  the  loca- 
tion, begins  on  the  right  or  the  left  side,  and  radiates  in  all 


292  DISEASES  OF  THE  DIGESTIVE  CANAL 

directions,  especially  toward  the  back.  The  affected  portion 
of  the  colon  is  especially  sensitive  to  pressure. 

In  obstruction  of  the  small  intestine,  distress  is  more 
constant  and  is  associated  with  rumbling  of  gases  in  the 
middle  of  the  abdomen  in  the  region  of  the  umbihcus, — which 
parts  are  also  sensitive  to  pressure. 

In  peritonitis,  there  is  constant  cutting  or  boring  pain. 

In  paralysis  of  the  intestine,  there  is  no  pain,  but  a 
dull  feeling  of  pressure,  fulness  and  distention,  corresponding 
to  the  meteorism. 

2.  Meteorism. — When  a  stenosis  of  the  intestine,  which 
has  been  gradually  developing,  suddenly  becomes  a  complete 
stenosis,  or  ileus,  it  gives  rise  to  visible  and  palpable  localized 
meteorism.  In  this  condition,  the  so-called  intestinal  "stif- 
fenings"  also  become  manifest  above  the  point  of  obstruction. 

This  is  rarely  present  in  cases  of  sudden  obstruction  of 
the  bowels,  for  the  reason  that  hypertrophy  of  the  muscles 
has  had  no  time  to  develop. 

If,  within  24  or  36  hours  after  the  onset,  the  peripheral 
region  of  the  abdomen  which  corresponds  to  the  course  of 
the  colon  becomes  tympanitic  and  distended,  and  the  middle 
portion  of  the  abdomen  is  sunken,  the  conditions  are  indica- 
tive of  an  obstruction  of  the  colon,  and  especially  of  the  sig- 
moid flexure  or  descending  colon. 

If,  on  the  other  hand,  the  peripheral  portion  of  the 
abdomen  is  not  distended,  and  the  middle  portion  is  tym- 
panitic, this  is  indicative  of  an  obstruction  at  some  point  above 
the  ileocsecal  valve,  provided  that  this  symptom  corresponds 
with  the  character  of  the  pain. 

This  is  equally  true,  even  if  gas  still  escapes  from  the 
intestine,  and  if  enemata  are  successful  in  showing  the  presence 
of  some  fecal  matter. 

Two  or  three  days  after  complete  stenosis  has  set  in, 
the  entire  intestinal  tube  will  be  distended,  so  that  by  this 
time  meteorism  will  be  of  no  value  in  localizing  the  lesion. 

3.  Vomiting. — Constant,  non-feculent  vomiting  of  every- 
thing eaten,  and  of  bile,  is  indicative  of  either  peritonitis  or 


DISEASES  OF  THE  INTESTINE  293 

an  obstruction  located   high  up  in  the  intestinal  tube, — for 
instance,  in  the  jejunum  or  the  duodenum. 

If  fecal  vomiting  occurs  within  twenty-four  or  thirty- 
six  hours  after  the  onset  of  the  trouble,  it  is  significant  of 
obstruction  of  the  small  intestine;  and  if  after  two  or  three 
days,  it  indicates  an  obstruction  of  the  large  intestine.  In  a 
deeply  located  obstruction, — for  instance,  one  between  the 
sigmoid  flexure  and  the  rectum, — vomiting  may  be  entirely 
absent,  or  it  may  appear  six  or  seven  days  after  the  illness, 
or  not  until  a  short  time  before  death. 

4.  Enemata. — If  the  injected  fluid, — water  or  oil, — returns 
after  the  injection  of  from  five  to  seven  hundred  cubic  centi- 
metres, it  is  probable  that  the  obstruction  is  located  low  in  the 
large  bowel,  or  that  there  is  insufficiency  of  the  sphincter  ani. 
If,  on  the  other  hand,  one  or  two  litres  can  be  injected,  it  is 
quite  evident  that  the  seat  of  the  occlusion  lies  above  the  colon. 

5.  Temperature. — Fever  at  the  beginning  of  the  illness 
is  indicative  of  peritonitis;  while  if  the  febrile  reaction  occurs 
at  a  later  period,  it  indicates  some  other  condition  which  is 
complicated  by  peritonitis. 

It  is  self-evident  that  one  may  establish  a  fairly  accurate 
diagnosis  only  when  all  of  these  five  symptoms  harmonize 
with  one  another. 

Differential  Diagnosis. — It  is  impossible  to  describe  in 
detail,  in  this  book,  all  of  the  many  varieties  of  ileus. 

Treatment. — Internal  medication  is  ineffective  in  volvu- 
lus and  strangulation;  but  in  mechanical  occlusion  and  invagi- 
nation of  the  gut,  it  will  often  produce  good  results. 

Laxatives  should  be  given  only  when  there  is  neither 
coUc  nor  fever.  Three  or  four  tablespoonfuls  of  castor  oil, 
or  one  tablespoonful  of  Carlsbad  salts,  dissolved  in  a  pint  of 
lukewarm  water,  should  be  given,  besides  using  high  enemata, 
consisting  of  two  or  three  Htres  of  warm  water  at  a  tempera- 
ture of  30°  to  32^^  R.  [100°— 104°  F.],  since  in  such  cases  it  is 
highly  probable  that  there  is  only  a  fecal  impaction. 

If  colic,  with  or  without  moderate  fever,  is  a  symptom, 
0.001  to  0.0015   [eV-To  gi"-]  of  atropine   sulphate    should   be 


294  DISEASES  OF  THE  DIGESTIVE  CANAL 

given  every  three  hours  by  mouth,  or  subcutaneously  if  there 
is  vomiting;  and  an  enema  of  one  to  one  and  one-half  Htres 
of  warm  sesame  oil  should  be  introduced,  if  a  movement  of 
the  bowels  does  not  follow  enemata  of  water. 

If  fever  is  present  from  the  onset  of  the  illness,  the  ice- 
bag  should  be  used,  and  suppositories  containing  0.1  [gr.  issl 
of  the  extract  of  opium  and  0.05  [§  gr.]  of  the  extract  of  bella- 
donna should  be  introduced  into  the  rectum  three  times  daily. 

Diet. — The  only  foods  allowed  are  champagne,  ice-cold 
milk,  cream,  lemonade,  peppermint-tea,  and  egg-cognac. 

It  is  safe  to  continue  the  above-mentioned  therapy  for 
five  or  six  days,  in  case  no  alarming  symptoms  occur, — such 
as  stercoral  vomiting,  singultus,  fever,  severe  sensitiveness  to 
pressure,  thread-like  pulse  or  collapse. 

The  physician  should  always,  under  the  last-named  con- 
ditions, advise  operative  treatment,  unless  it  is  evident  that 
an  inoperable  cancer  is  the  cause  of  the  obstruction,  in  which 
case, — to  prevent  pain, — opium  or  morphine  should  be  given 
by  mouth,  or  subcutaneously  if  there  is  vomiting. 

In  some  instances  it  may  seem  advisable,  as  a  palliative 
measure,  to  create  an  artificial  anus. 

Since  the  clinical  picture  of  ileus  presents  such  A^aried 
phases,  I  consider  it  quite  useless  to  attempt  to  illustrate  the 
disease  by  clinical  cases,  for  two  given  cases  will  very  rarely 
run  the  same  clinical  course. 

Acute  and  Chronic  Peritonitis 

Since  the  peritoneum  is  so  often  diseased  as  the  result 
of  acute  and  chronic  organic  affections  of  the  digestive  tract, 
it  seems  advisable  to  discuss  briefly  the  clinical  character- 
istics of  peritonitis,  especially  since  it  must  be  differentially 
diagnosticated  from  ileus,  as  has  been  mentioned  in  the  pre- 
vious chapter. 

Etiology, — ^With  the  exception  of  the  rare  idiopathic 
form,  peritonitis  is  always  secondary  to  an  inflammatory 
affection  of  the  serous  membrane  covering  any  of  the  abdomi- 
nal or  pelvic  organs. 


DISEASES  OF  THE  INTESTINE  295 

First  to  be  discussed  is  Circumscribed  Peritonitis,  which 
is  limited  to  a^relatively  small  area  of  the  peritoneum. 

Circumscribed  peritonitis, — as  has  already  been  men- 
tioned above  in  discussing  perigastritis, — results  from  deep- 
seated  ulceration  of  the  stomach  or  intestine,  from  malignant 
neoplasms  of  the  intestine,  from  pericolitis,  perityphlitis, 
periduodenitis,  pericholecystitis,  perisigmoiditis,  from  trauma, 
or  from  inflammation  of  the  uterus  and  its  adnexa.  The 
adhesions  which  form  between  the  serous  membranes  of  the 
various  organs  often  prevent  the  diffusion  of  an  inflammation, 
even  after  perforation. 

Diffuse  General  Peritonitis  results  from  perforation  at 
a  time  when  there  are  insufficient  adhesions  or  none  at  all, 
to  prevent  the  spread  of  the  infection. 

Chronic  Circumscribed  Peritonitis  accompanies  chronic 
ulceration  of  the  stomach  or  intestine. 

Generalized  Chronic  Peritonitis  is  usually  of  a  tuber- 
cular nature. 

In  peritonitis,  as  in  pleurisy,  there  is  a  dry,  adhesive 
form,  and  also  an  exudative  form.  The  exudate  in  the  latter 
is  either  serous  or  purulent,  according  to  the  type  of  the 
infection.  Finally,  there  may  be  both  circumscribed  and 
diffuse  general  peritonitis,  as  in  subphrenic  abscess,  associated 
with  a  generalized  purulent  peritonitis. 

Diagnosis. — The  symptoms  in  the  different  forms  of  the 
disease  are  often  so  atypical,  that  an  exact  diagnosis  is  some- 
times impossible. 

1.    Localized  Peritonitis  of  the  Adhesive  Type 

The  onset  is  gradual.  The  first  symptoms  usually  appear 
after  sudden  and  active  exercise,  heavy  lifting,  coughing  or 
straining;  later,  pain  becomes  spontaneous,  especially  if  the 
patient  hes  on  the  side  opposite  to  the  seat  of  the  lesion, 
which  produces  traction  upon  the  adhesion.  Pain  is  increased 
by  pressure  over  the  seat  of  the  disease,  as  well  as  by  active 
peristalsis,  or  distention  of  the  bowels  by  gas.  There  is  no 
fever,  and  nausea  and  vomiting  are  rare. 


296  DISEASES  OF  THE  DIGESTIVE  CANAL 

Sometimes  the  abdomen  over  the  diseased  portion  of  the 
peritoneum, — especially  in  patients  with  relaxed  abdominal 
walls, — appears  thickened  on  palpation. 

IMany  times,  such  patients  are  mistakenly  considered  to  be  hypo- 
chondriacal or  hysterical, — notwithstanding  the  fact  that  actual  and  severe 
pain  in  the  abdomen  occurs  only  in  organic  diseases. 

The  above-described  circumscribed  adhesive  peritonitis 
occurs  with  especial  frequency  in  perigastritis,  pericolitis,  or 
following  strangulated  hernia?  and  laparotomies. 

Rest  in  bed,  hot  apphcations,  and  treatment  which  con- 
trols meteorism  and  lessens  peristalsis,  will  relieve  the  pain 
incident  to  this  form  of  disease. 

2.  Circumscribed  Exudative  Peritonitis 

The  exudation  may  be  serous  or  purulent,  as  in  fecal 
abscesses,  and  may  rupture  into  the  lumen  of  the  intestine, 
the  urinary  bladder,  or  externally. 

The  onset  of  the  affection  is  usually  quite  sudden,  with 
severe  pain  over  a  localized  area, — so  severe  that  the  patient 
must  immedi-ately  assume  a  recumbent  position;  this  pain  is 
increased  by  pressure,  and  there  is  a  distinct,  balloon-like 
resistance  to  palpation.  Certain  movements  or  positions  of 
the  body,  and  also  hot  compresses,  will  increase  the  pain, 
which  however  is  reUeved  by  the  ice-bag.  Either  moderate 
or  high  fever  is  present.  Vomiting  is  generally  absent,  al- 
though nausea  is  a  common  symptom. 

This  form  of  peritonitis  is  associated  with  chronic  ulcer- 
ation of  the  stomach  and  intestine,  which  have  perforated 
through  adhesive  inflammation  into  an  already  encysted 
cavity;  and  it  also  occurs  after  trauma  which  has  ruptured 
some  internal  organ,  when,  under  favorable  circumstances, 
adhesions  rapidly  form. 

3.    Diffuse  Exudative  (Serous  or  Purulent)  Peritonitis 

This  is  characterized  by  intense,  constant,  cutting, 
boring,  but  rarely  cohcky  pain  in  the  entire  abdomen,  which 
is  most  intense  at  its  point  of  origin, — for  example,  in  the 


DISEASES  OF  THE  INTESTINE  297 

appendix  or  gall-bladder.  It  radiates  in  all  directions,  and  is 
increased  by  the  slightest  touch  or  movement.  Vomiting  is 
very  frequent.  Usually  there  are, — besides  a  small,  thread- 
like pulse, — singultus,  and  the  fades  Hippocraiica. 

Scarcely  any  relief  from  suffering  is  obtained  by  the 
use  of  the  ice-bag  or  by  moderate  doses  of  narcotics.  Micturi- 
tion is  painful,  and  meteorism  gradually  develops  to  enormous 
proportions.  There  is  almost  complete  paralysis  of  the  bowels, 
so  that  neither  faeces  or  gas  can  escape  from  the  rectum.  The 
temperature  is  rarely  high,  and  may  fall  to  normal  in  collapse, 
as  it  always  does  before  death. 

This  form  of  peritonitis  is  caused  by  perforation  of  any 
part  of  the  gastro-intestinal  canal,  gall-bladder,  Fallopian 
tubes,  etc.,  when  no  adhesions  are  present  to  limit  the  spread 
of  the  inflammation. 

4.     Diffuse  Chronic  Peritonitis 

This  is  usually  of  a  tubercular  nature,  and  is  character- 
ized by  stabbing,  cutting  pain  which  occurs  now  in  one  part 
of  the  abdomen,  now  in  another,  and  which  is  caused  by 
intestinal  peristalsis,  and  is  increased  by  heavy  movements 
or  pressure.  Alleviation  of  the  pain  is  usually  experienced 
from  the  use  of  the  ice-bag  and  the  administration  of  bella- 
donna,— which  lessen  the  peristaltic  action  of  the  gut. 

The  amount  of  exudate  is  usually  moderate,  and  is  fre- 
quently encapsulatecj. 

There  is  little  or  no  fever,  the  stools  are  regular  or  moder- 
ately constipated,  and  there  are  occasional  nausea  and  vomit- 
ing.    Other  signs  of  tuberculosis  are  usually  present. 

The  course  of  the  disease  may  extend  over  a  period  of 
several  months  or  a  year,  sometimes  resulting  in  recovery, 
but  usually  in  death  from  debility. 

TREATMENT 

1.  The  treatment  of  Circumscribed  Adhesive  Peritonitis 
consists  in  absolute  rest  in  bed,  the  application  of  hot  oatmeal 
compresses,  mud-poultices,  a  thermal  coil,  etc.;  the  internal 
administration  of  0.03  [gr.  ^]  of  extract  of  belladonna  three 


298  DISEASES  OF  THE  DIGESTIVE  CANAL 

times  dail}',  administered  bj'  mouth  or  rectum,  according  to 
the  location  of  the  affection;  and  the  apphcation  of  one  or  two 
leeches  over  the  seat  of  the  lesion. 

Proph3'lactic  treatment  consists  in  the  use  of  abdominal 
bandages,  suitable  hernia  trusses,  and  the  avoidance  of  violent 
demands  upon  the  musculature  of  the  abdominal  wall,  as  in 
hard  manual  labor,  sports,  etc. 

2.  Fecal  Abscess. — In  this  condition  treatment  should 
consist  of  rest  in  bed  and  the  use  of  the  ice-bag;  belladonna 
as  above  indicated;  the  apphcation  of  one  or  two  leeches; 
and  eventual  incision. 

3.  Diffuse  Purulent  Peritonitis. — Internal  treatment 
should  be  limited  to  the  use  of  anodyne  remedies, — of  which 
the  best  is  morphine,  given  three  times  daily  in  doses  of  0.02 
to  0.03  [^-^  gr.],  or  atropine  sulphate  0.001  [gV  gr.],  given 
subcutaneously  three  times  daily.  Ice-compresses  are  pref- 
erable to  the  ice-bag.  Sometimes  painting  the  abdomen  with 
oil  of  turpentine  is  helpful. 

The  decision  as  to  whether  an  operation  should  be 
attempted  should  be  left  to  the  judgment  of  the  surgeon. 

4.  Chronic  Peritonitis. — The  treatment  giving  greatest 
relief  to  the  patient  consists  in  the  apphcation  of  towels 
wrung  out  of  ice-water,  the  internal  administration  of  0.02 
ih  gi'-]  of  belladonna,  or  0.0005  [j^^  gr.]  of  atropine  sulphate 
three  times  daily,  the  occasional  use  of  leeches,  and  smearing 
the  abdomen  with  green  soap. 

Incision  should  eventually  be  made,  in  case  the  exuda- 
tion is  circumscribed. 

Diet. — In  the  first  two  forms  of  peritonitis,  the  diet  should 
be  Hmited  to  assimilable  and  nourishing  foods  of  hquid  or  semi- 
sohd  consistency, — such  as  broth,  tea,  or  coffee  with  cream, 
beef-tea,  fruit  ices,  lemonade,  egg-cognac,  and  champagne. 

In  the  third  form,  the  diet  should  be  stimulating,  — con- 
taining wines,  etc. 

In  the  fourth  form  of  the  disease,  the  food  should  be 
non-irritating,  but  strengthening,  in  order  to  increase  the 
patient's  resistance  against  the  infection;    the  most  suitable 


DISEASES  OF  THE  INTESTINE  299 

dietary  consisting  in  the  daily  use  of  a  pint  of  cream  in  tea  or 
coffee,  three  or  four  yolks  of  eggs,  100  to  150  grams  of  butter, 
puddings  with  fruit-sauces,  besides  chicken,  pigeon,  white 
bread,  rice,  noodles,  or  light  vegetables  in  puree  form,  caviare, 
and  Hungarian  wine. 

FUNCTIONAL  DISEASES  OF  THE  INTESTINE 
Chronic   Constipation 

We  speak  of  chronic,  habitual  obstipation,  or  constipa- 
tion, when  there  is  a  diminution  or  a  complete  cessation  of 
spontaneous  evacuations  of  the  stool.  There  are,  therefore, 
complete  and  incomplete  forms  of  chronic  constipation,  accord- 
ing to  whether  the  patient  must  constantly,  frequently,  or 
only  occasionally  resort  to  the  use  of  a  laxative  or  an  enema. 

The  incomplete,  associated  with  the  formation  of  so- 
called  residual  faeces,  is  generally  the  forerunner  of  complete 
constipation. 

There  are  many  individuals  that  have  used  laxatives  for 
decades,  even  from  childhood,  and  have  never  be;en  ill  nor 
suffered  any  serious  consequences, — satisfactory  results  having 
been  obtained  from  the  use  of  one  laxative  after  another, 
recommended  by  physicians  or  by  the  laity. 

Patients  have  rarely  consulted  me  for  constipation  at  a 
time  when  laxative  remedies  were  still,  even  to  a  slight  degree, 
effective. 

There  comes  a  time,  early  or  late,  however,  when  all 
laxative  remedies  and  enemata  become  ineffective.  It  is  then 
that  such  persons,  having  formerly  considered  their  condition 
as  unimportant,  realize  that  they  are  ill,  and  consult  a  physician. 

It  is  self-evident  that  the  earlier  the  patient  has  rational 
treatment,  the  more  successful  will  be  the  results.  Cases  which 
have  existed  for  several  years,  or  for  decades,  often  require 
many  months'  treatment  in  a  sanitarium  to  be  cured. 

The  therapy  depends  entirely  upon  the  variety  of  con- 
stipation, and  upon  the  physician's  ability  to  find  the  etio- 
logical   factors    in    each    individual    case.      When    these    are 


300  DISEASES  OF  THE  DIGESTIVE  CANAL 

established,  it  is  eas}!-  to  determine  the  rational  therapy, 
which  results  successfully  in  by  far  the  majority  of  cases. 

In  the  following  discussion,  therefore,  I  have  laid  the 
chief  emphasis  on  these  two  points. 

Etiology. — The  causes  of  chronic  constipation  are  natur- 
ally grouped  as  follows: 

1.  Bad  Habits;  Neglect;  Prudery;  Lack  of  Time; 
Indolence,  etc. 
In  this  group  belong  many  school-girls  and  women  living 
in  boarding-houses,  who,  on  account  of  prudery,  do  not  go  to 
stool  regularly;  also  office-people  and  business  men,  who,  at 
the  time  when  the  need  manifests  itself,  are  too  busy  to 
respond.  In  such  persons,  the  normal  sensation  of  the  rectum 
has  gradually  been  lost  through  the  unnatural  suppression 
of  the  desire  to  go  to  stool;  hence  they  resort  to  purgatives 
and  laxatives,  as  a  matter  of  convenience,  and  so  habituate 
themselves  to  their  use  that  they  are  gradually  obliged  to 
employ  stronger  and  stronger  remedies,  until  finally  all  have 
lost  their  effect. 

2.  Insufficient  Exercise,  Sedentary  Occupations 
and  Obesity 
To  this  group  of  patients  belong  many  officials,  book- 
keepers, coachmen,  students,  etc.,  who  are  seated  the  greater 
part  of  the  day,  and  also  obese  persons  who  take  too  Httle 
exercise  and  who  do  not  go  to  stool  as  frequently  as  they 
should,  because  of  the  inconvenience  or  because  it  is  difficult 
for  them  to  use  the  abdominal  muscles  at  stool. 

3.  Diminution  of  Power  of  Expulsion  of  the  Intestinal 
Musculature  and  Abdominal  Pressure 
To  this  group  belong  patients  with  congenital  or  accjuired 
enteroptosis,  especially  women  who  have  borne  children 
and  who  have  diastasis  of  the  recti  muscles  and  pendulous 
abdomen,  and  also  those  who  have  a  relaxed  peritoneum, 
following  lacerations. 


DISEASES  OF  THE  INTESTINE  301 

Whether  in  these  cases  the  musculature  of  the  colon  is  indeed  anatom- 
ically weakened,  or  only  badly  innervated,  cannot  be  determined  with 
positiveness. 

It  is  most  probable  that  the  condition  of  the  colon  corresponds  to  that 
of  the  rest  of  the  body  in  such  patients  as  are  under-nourished  and  anaemic. 
Since,  however,  the  constipation  entirely  disappears  by  proper  therapy,  it 
may  be  quite  positively  assumed  that  the  trouble  was  of  a  functional  nature. 

To  this  group  belong  a  large  majority  of  patients  suffer- 
ing from  chronic  constipation.  Very  frequently  the  physician 
is  able  to  trace  the  beginning  of  the  trouble  to  the  first  preg- 
nancy and  puerperium.  But  this  form  of  chronic  constipa- 
tion occurs  equally  often  in  nulliparce  and  in  men  who  have 
the  habitus  enteropticus,  associated  with  a  general  malnutrition. 

This  intestinal  condition  corresponds  to  ansemic-gastrop- 
totic  dyspepsia.  It  need  only  be  mentioned  here  that  the 
stomach  and  intestine  are  often  involved  simultaneously,  or  an 
affection  of  the  one  follows  that  of  the  other,  as  a  result  of 
these  disturbances  of  the  functions  of  the  gastro-intestinal  tract. 

4.  Insufficient  and  Unsuitable  Food 
Most  of  the  patients  in  this  group  are  those  with  poor 
or  perverted  appetites, — such  as  phthisical  or  neurasthenical 
individuals,  or  those  who  through  ignorance  have  subsisted 
largely  on  proteid  foods,  avoiding  vegetables  and  fruit  because 
they  did  not  consider  them  nourishing  and  strengthening. 
Children  especially  suffer  from  constipation  as  the  result  of 
such  a  diet-error. 

5.  Disease  of  the  Stomach  in  which  the  Nourishment  taken  is 
either  too  Limited  in  Amount  or  Too  Bland  and  Non- 
Irritating  in  Quality 

In  this  group  should  be  mentioned  first  the  organic  dis- 
eases of  the  stomach, — such  as  chronic  gastritis,  ulcer,  ectasia, 
and  carcinoma, — in  which  the  patient,  partly  on  account  of 
the  loss  of  appetite  and  partly  from  fear  of  eating,  or  because  the 
motiUty  of  the  stomach  is  disturbed  by  an  organic  obstruction, 
has,  upon  the  advice  of  a  physician,  avoided  those  foods  which 
give  bulk  to  the  faeces,  and  this  in  turn  has  caused  constipation. 


302  DISEASES  OF  THE  DIGESTIVE  CANAL 

In  functional  diseases  of  the  stomach,  patients  suffer 
from  constipation  as  a  result  of  taking  insufficient  amounts  of 
food,  because  they  fear  the  resulting  pressure  and  fulness  in 
the  epigastrium, — sjaiiptoms  which  they  often  consider  due 
to  chronic  catarrh  of  the  stomach. 

6.  Diseases  of  the  Intestine,  such  as  Catarrh,  Inflammation  in 
the  Ileoccecal  Region,  and  the  Misuse  of  Laxatives 

In  this  group  we  should  first  mention  typhlitis  and 
appendicitis,  because  they  are  often  treated  with  large  doses 
of  opium,  which  frequently  leaves  behind  a  persistent  con- 
stipation. Laparotomies  have  the  same  effect,  for  in  addition 
to  the  paralyzing  influence  of  narcptics  and  anaesthetics  upon 
the  intestine,  there  is  a  weakening  of  the  muscles  involved  in 
the  downward  abdominal  pressure. 

Another  common  disease  of  this  group  is  chronic  catarrh 
of  the  intestine,  which  frequently  causes  chronic  constipation, 
as  a  result  of  a  spastic  condition  of  the  musculature  of  the 
colon,  as  has  been  pointed  out  in  the  chapter  on  Enterocolitis. 

7.   Nervous    Influences:     Hysteria,    Tabes    Dorsalis,    Lead 
Intoxications,  etc. 

Chronic  constipation  occurs  in  hysteria  from  impair- 
ment of  the  innervation  of  the  intestinal  wall.  The  muscula- 
ture may  be  either  too  much  relaxed  or  too  strongly  con- 
tracted. A  period  of  atonic  constipation  usually  pre- 
cedes the  spastic  stage,  which  does  not  appear  until 
pathological  alterations  in  the  mucous  membrane  of  the 
colon   have    occurred. 

In  general,  it  may  be  said  that  the  stage  of  spastic  con- 
stipation occurs  earher  in  hysterical  individuals  than  in  those 
who  have  no  neurotic  tendencies. 

Disturbances  of  intestinal  innervation  which  lead  to 
chronic  constipation  frequently  occur  in  cases  of  tabes  dor- 
salis, because  such  patients  have  largely  lost  the  normal 
desire  to  go  to  stool. 

Chronic  leacl-poisoning  also  causes  spastic  constipation. 


DISEASES  OF  THE  INTESTINE  303 

It  is  assumed,  at  the  present  time,  that  this  occurs  as  a 
result  of  paralysis  of  the  splanchnic  nerves,  which  are  the 
inhibitory  nerves  of  the  automatic  ganglia  of  the  intestinal 
wall.  In  severe  cases  of  lead-poisoning,  the  spastic  condition 
of  the  bowels  frequently  develops  into  the  well-known  lead 
colic,  which  represents  merely  an  acute  exacerbation  of  the 
intoxication. 

8.   Local  Obstructions, — Stenoses,  Dilatations,  and  Neoplasms 
of  the  Intestinal  Tract 

In  such  cases,  the  constipation  is  merely  a  symptom  of 
the  pfimary  disease.  In  any  given  case,  the  presence  of  a 
tumor  which  narrows  the  lumen  of  the  intestine  from  within, 
or  compresses  it  from  without,  should  always  be  thought  of, 
as  well  as  hypertrophy  of  the  prostate  gland,  displacements 
of  the  uterus,  and  also  peritonitic  adhesions  with  neighboring 
organs, — such  as  the  liver,  the  anterior  abdominal  wall,  and 
the  female  genital  organs.  Laparotomies  and  traumata 
also  produce  the  same  results. 

That  portion  of  the  intestine  above  the  seat  of  the  ob- 
struction becomes  dilated,  just  as  does  the  stomach  when 
there  is  a  stenosis  of  the  pylorus. 

The  atonic  dilatation  of  the  sigmoid  flexure  should  be  mentioned  here, 
since  it  is  observed  with  especial  frequency  in  children  and  may  lead  to 
enormous  sack-shaped  dilatation  of  this  portion  of  the  intestine.  The  exces- 
sive length  of  the  mesentery  is  responsible  for  this  condition,  since  it  allows 
a  kinking  of  the  colon  at  this  place.  This  condition  has  been  given  the  name 
of  "Hirschsprung's  Disease,"  after  the  clinician  who  first  described  it. 

THE    DEVELOPMENTAL    STAGES    OF    CHRONIC    CONSTIPATION 

To  be  successful  in  the  treatment  of  any  given  case  of 
constipation,  it  is  essential  for  the  physician  to  be  able  not 
only  to  find  its  etiological  factor,  but  also  to  recognize  the 
stage  of  its  development. 

I  recognize  that  the  classification  of  constipation  wdiich 
I  shall  present  in  the  following  pages  is  somew^hat  schematic, 
and  the  arrangement  of  the  different  forms  may  not,  in  some 


304  DISEASES  OF  THE  DIGESTIVE  CANAL 

instances,  be  strictly  correct;  yet  the  plan  of  the  subject  as 
outlined  has  proven  so  satisfactory  to  me  in  practice,  that  I 
do  not  hesitate  to  adhere  to  it  in  this  book. 

1.  Atonic  Stage 

Except  in  neurasthenically-disposed  individuals,  chronic 
constipation  always  begins  with  this  stage,  in  which  the  mus- 
culature of  the  colon  is  relaxed. 

[It  appears,  from  the  investigations  of  Schmidt  and 
Strassburger,  that  this  stage  of  constipation  is  due,  not  to 
atony  of  the  intestinal  musculature,  but  to  too  complete 
digestion  and  absorption  of  food  in  the  intestine.  As  a  result 
of  this,  the  intestinal  bacteria  have  not  food  enough  left  for 
their  growth,  and  are  therefore  unable  to  form  gases,  acids, 
and  other  substances  which  appear  to  be  normal  stimulants 
to  the  intestinal  wall;  and  the  intestine,  lacking  this  stimu- 
lation, fails  in  its  peristaltic  action.  Lohrisch*has  under- 
taken the  systematic  investigation  of  the  stools  of  patients 
suffering  from  constipation,  while  on  the  test-diet.  He  found 
that  the  normal  dried  substance  of  the  stools  of  three  days' 
diet  averaged  59.3  grams,  while  in  constipation  it  averaged 
but  33.9  grams.  This  indicated  that  the  digestion  and  absorp- 
tion had  been  too  perfect.  He  found  that  when  he  gave  opium 
to  normal  persons, — which  would  produce  a  condition  sim- 
ulating atony  of  the  bowels,— only  the  watery  elements  of  the 
stool  were  reduced,  while  the  dried  substance  was  not  altered. 
This  indicates  that  lack  of  peristalsis  cannot,  of  itself,  produce 
the  condition  that  has  been  called  atonic  constipation.  No 
doubt,  weakness  of  the  muscles  of  the  bowels  plays  some  part 
in  the  production  of  constipation,  but  it  does  not  appear  to 
be  the  most  important  factor. 

The  most  prominent  causes  seem  to  be  a  too  perfect 
digestion  and  absorption  of  food,  poor  growth  of  the  normal 
bacteria  of  the  bowel,  and  a  consequent  lack  of  the  normal 
products  of  fermentation.] 

{*Deutsch.  Arch.  f.  klin.  Med.,  1904,  Bd.  79,  p.  383.] 


DISEASES  OF  THE  INTESTINE  305 

2.  Catarrhal  Stage 

This  follows  after  the  atonic  stage  has  existed  for  years 
or  decades,  as  a  result  of  the  irritating  effect  of  the  scybala 
upon  the  intestinal  mucosa,  or  from  the  abuse  of  laxatives. 

The  diagnosis  of  this  stage  is  made  possible  by  the  presence 
of  membranous  mucus  surrounding  the  scybala. 

We  do  not  accurately  know  the  real  condition  of  the  small 
intestine  at  this  stage.  We  must  assume,  however,  on  the 
occurrence  of  flatulence  during  this  period,  that  a  catarrhal  con- 
dition is  gradually  developing  in  this  part  of  the  intestinal  canal. 

3.  Sjjastic  Stage 
This  stage  of  constipation  occurs  as  soon  as  the  secondary 
enterocolitis,  or  the  abuse  of  laxatives,  has  irritated  the  colon 
so  that  a  persistent  hypertonicity  of  its  musculature  has 
developed.  In  nervous,  and  especially  in  hysterical,  individ- 
uals this  stage  sets  in  considerably  earlier  than  in  a  person 
whose  nervous  system  is  in  a  normal  condition. 

4.  Membranous  Enteritis 

This  stage  of  constipation  is  still  designated  by  a  few 
authors  as  a  "myxoneurosis"  of  the  intestinal  canal;  but,  as 
has  already  been  mentioned,  it  is  merely  an  advanced  stage  of 
chronic  colitis. 

The  more  marked  is  the  stagnation  of  scybala  in  the  colon, 
the  more  active  is  the  secretion  of  mucus  from  Lieberkiihn's 
glands  of  the  mucosa;  and  since  the  faeces  are  often  retained 
for  several  days,  on  account  of  the  contracted  condition  of  the 
colon,  there  is  produced  a  large  amount  of  mucus  as  a  result 
of  the  absorption  of  the  fluid  constituents,  as  well  as  from  the 
astringent  effect  of  the  acid  faeces,  and  the  mucus  assumes  a 
membranous  formation  which  may  be  evacuated  as  an  isolated 
cyUnder  of  mucus,  or  may  be  expelled  together  with  the  faeces, 
completely  surrounding  the  latter. 

5.  Mucous  Colic 
The  so-called  "mucous  coHc"  is  merely  an  acute  exacer- 
bation of  membranous  colitis.     When  the  contraction  of  the 
20 


306  DISEASES  OF  THE  DIGESTIVE  CANAL 

colon  is  too  strong,  obstructing  the  lumen  of  the  gut,  nature 
attempts  to  expel  the  mucus  by  violent  peristaltic  contractions 
of  the  colon,  which  cause  great  pain. 

During  these  attacks,  the  patient  often  expels  a  glassful 
of  mucus,  which,  when  suspended  in  water,  reveals  its  mem- 
branous formation. 

After  the  evacuation  of  large  masses  of  mucus,  the  patient 
is  generally  free  from  pain  for  some  time,  and  presents  during 
this  period  only  the  picture  of  simple  spastic  constipation, 
until  another  attack  occurs. 

6.  Stercoral  Diarrhopa 

In  very  advanced  cases  of  secondary  catarrh  of  the  intes- 
tine, chronic  constipation  may  develop  into  diarrhoea.  Such 
patients  then  generally  suffer  from  alternating  constipation 
and  diarrhoea;  for  instance,  after  diarrhoea  has  existed  for 
about  a  week,  there  is  a  period  of  absolute  constipation. 

These  clinical  cases  are  rather  rare,  but  are  found  with 
some  frequency  in  neuropathic  individuals,  or  in  patients  who 
have  been  improperly  treated  for  constipation.  The  secondary 
catarrh  occupies  the  foreground  in  the  chnical  symptoms  so 
prominently  that  only  by  the  most  careful  anamnesis  and 
examination  can  the  physician  trace  its  origin  to  a  previous 
chronic  constipation. 

DIFFERENTIAL    DIAGNOSIS    OF    THE    VARIOUS    STAGES    OF 
CHRONIC    CONSTIPATION 

Atonic. — In  this  period  of  the  disease,  patients  complain 
of  nothing  more  severe  than  constipation,  a  dull  feeling  in  the 
head,  lack  of  desire  to  work,  etc.  Enemata  and  laxatives  are 
both  effective,  but  the  latter  must  be  changed  frequently. 
There  is  no  pain,  flatulence,  nor  meteorism. 

In  the  objective  examination,  the  physician  will  find  the 
stool  of  normal  form  and  consistency,  i.e.,  of  large  caliber, 
and  covered  only  with  the  normal  amount  of  mucus. 

The  sigmoid  flexure,  and  usually  the  transverse  colon  as 
well,  will  be  found  filled  with  faeces  which  may  usually  be 
palpated. 


DISEASES  OF  THE  INTESTINE  307 

Catarrhal. — This  stage  is  recognized  subjectively  by  the 
occurrence  of  flatulence  after  the  use  of  irritating  foods,  such 
as  flatulent  vegetables,  pastries,  fat  meats,  cold  drinks,  etc. 

Objectively,  it  is  recognized  by  the  admixture  of  mucus 
with  the  stool. 

Spastic. — This  stage  of  chronic  constipation  occurs  almost 
simultaneously  with  membranous  enteritis,  and  is  easily 
differentiated  from  the  atonic  stage  by  the  following  signs 
and  symptoms: 

1.  Colic  is  a  frequent  symptom.  In  shght  cases,  patients 
have  flatulent  colic;   and  in  severe  cases,  mucous  colic. 

Every  case  of  chronic  constipation  that  runs  its  course 
with  attacks  of  pain  belongs  to  the  spastic  variety,  in  which 
inflammatory  and  catarrhal  changes  of  the  intestinal  tube  are 
demonstrable. 

2.  Laxatives  are  either  not  effective  at  all,  or  only  so 
when  given  in  very  large  doses,  which  produce  great  pain, 
Enemata  likewise  are  usually  ineffective. 

3.  Objectively,  on  palpation,  the  contracted  transverse 
colon  and  the  sigmoid  flexure  of  the  colon  are  found  to  resemble 
a  hard  cord,  about  the  size  of  the  little  finger.  The  colon  in 
this  condition  is  sensitive  to  pressure. 

4.  Digital  examination  of  the  rectum  reveals  the  fact 
that  it  is  either  entirely  empty  and  contracted,  or  else  is  filled 
with  faeces  the  size  of  the  little  finger;  while  in  atonic  con- 
stipation the  rectum  is,  as  a  rule,  entirely  filled.  In  spastic 
constipation,  the  physician  can  frequently  feel  the  contraction 
of  the  intestinal  tube  around  the  palpating  finger. 

5.  The  stool  is  of  small  caliber, — about  the  size  of  the 
little  finger.  It  is  sometimes  ribbon-shaped,  or  its  transverse 
section  may  sometimes  be  quadrangular.  It  would  be  an 
error,  however,  to  assume  from  this  that  an  organic  stenosis 
exists  in  the  lower  portion  of  the  colon,  since  these  configur- 
ations of  the  faeces  may  likewise  be  caused  by  a  spastic  con- 
traction of  the  intestinal  musculature.  In  many  instances, 
the  stool  consists  of  individual,  short  segments;  while  in  the 
atonic  form  it  is  of  large  caliber  and  tubular. 


308  DISEASES  OF  THE  DIGESTIVE  CANAL 

,6.  Very  frequently,  besides  the  above  symptoms,  the 
physician-  will  observe  the  above-mentioned  membranous 
mucus.  In  a  doubtful  case,  to  demonstrate  whether  this  is 
present,  the  patient  should  insert  a  soap  suppository  into  the 
rectum  and  examine  the  resulting  stool,  placing  it  in  warm 
water,  when  the  mucus  will  spread  out  upon  the  surface  of  the 
water  and  thus  be  easily  recognized.  Or  the  examiner  may 
follow  the  procedure  of  Boas,— flushing  the  intestine  with  one 
or  two  litres  of  water,  small  amounts  at  a  time,  and  examining 
the  return  lavage-water  for  mucus.  The  lavage-apparatus 
described  by  Zweig  may  also  be  used  for  this  purpose.* 

By  these  subjective  and  objective  signs  and  symptoms, 
it  is  possible  in  most  cases  to  determine  the  stage  of  the  disease 
in  any  given  case  of  chronic  constipation. 

Mucous  cohc  is  very  easily  recognized,  especially  since  the 
patient  will  frequently  bring  the  characteristic  defecations  to 
the  physician,  with  the  mistaken  idea  that  he  has  a  tapeworm. 

The  stage  of  mucous  diarrhoea,  or  so-called  stercoral 
diarrhoea,  is  also  easy  of  recognition.  It  is  necessary,  however, 
to  prove  by  the  anamnesis  that  constipation  has  existed  for 
several  years  previous  to  the  diarrhoeal  stage. 

TREATMENT 

For  the  rational  treatment  of  chronic  constipation,  it  is 
unqualifiedly  necessary  to  have,  in  every  concrete  case,  a  clear 
understanding  of  the  etiological  factors  and  the  stage  of  the 
disease  from  which  the  patient  is  suffering. 

Atonic  Stage  of  Constipation. — The  sole  indication 
for  treatment  of  this  period  of  constipation  is  to  produce 
spontaneous  movements  of  the  bowel. 

The  application  of  the  following  fundamental  principles 
will  accompHsh  this  in  the  majority  of  cases: 

Hygiene. — The  physician  should  regulate  the  life  of  the 
patient  by  written  directions,  so  that  all  causative  factors  of 
constipation,  such  as  sedentary  habits  and  occupations,  may 

*  Therapie  der  Gegenwart,  April,  1906. 


DISEASES  OF  THE  INTESTINE  309 

be  avoided;  and  the  patient  should  be  advised  to  take  up 
gymnastics,  swimming,  riding,  walking  to  and  from  business 
or  school,  etc. 

Gymnastic  exercises  are  especially  suitable  for  women  with  relaxed 
and  weakened  abdominal  muscles.  Exercises  should  be  carried  out  night 
and  morning,  as  follows : 

With  the  hands  clasped  behind  the  head,  the  patient  should  raise  and 
lower  the  trunk  six  to  ten  times,  and  then  bend  the  trunk  forwards  and 
backwards,  besides  rotating  the  trunk  and  flexing  and  extending  the  legs. 

Mechanical  Treatment. — Patients  with  enteroptosis,  ''hang 
belly,"  and  diastasis  of  the  recti  muscles  should  wear  a  suitable 
abdominal  bandage  or  support,  and  should  have  massage, — at 
first  daily  and  later  only  two  or  three  times  a  week.  As  a  rule,  25 
or  30  treatments  are  required,  which  should  be  given  as  follows : 

The  hand  should  be  lubricated  with  vaseline  and  placed 
flatly  extended  upon  the  ileocgecal  region,  and  the  entire  colon 
should  then  be  stroked  along  its  course  to  the  sigmoid  flexure, 
over  which  quite  strong  downward  pressure  should  be  exerted, 
when  the  hand  should  be  returned  to  the  caecum  and  the 
routine  movement  repeated.  The  treatment  should  last  from 
five  to  eight  minutes.  * 

In  the  first  one  or  two  weeks  of  treatment,  it  will  generally 
be  necessary  to  resort  to  the  use  of  enemata,  consisting  of  | 
litre  of  lukewarm  water,  every  second  clay  after  breakfast. 

It  must  be  emphasized,  however,  that  laxatives  should  be 
strictly  forbidden  and  patients  should  be  directed  to  go  to  the 
toilet  every  morning  after  breakfast. 

Hydrotherapy. — Hydratic  treatments, — such  as  cold 
friction,  douches,  half-baths,  and  fresh -water  baths, — are 
useful  only  in  the  atonic  form  of  constipation. 

Electrotherapy. — In  cases  which  respond  to  treatment 
stubbornly,  it  is  often  useful  to  apply  a  strong  faradic  current 
for  about  five  minutes,  using  a  flat  electrode  upon  the  abdo- 
rnen,  and  a  rectal  electrode  in  the  rectum.  One  of  the  older 
and  most  useful  methods  was  that  of  introducing  into  the 

*  I  have  not  entered  into  the  remaining  movements  and  details,  for  the 
reason  that  massage  cannot  be  theoretically  learned. 


310  DISEASES  OF  THE  DIGESTIVE  CANAL 

lower  bowels  100  to  150  c.c.  of  lukewarm  water,  through  a 
glass  funnel  and  Naunyn's  intestinal  tube,  in  order  to  estab- 
lish a  contact  between  the  membrane  of  the  rectum  and  the 
metal  of  the  electrode. 

I  have  obtained  espcciall}^  good  results  in  the  constipa- 
tion of  tabes  dorsalis  by  this  treatment. 

Diet. — The  diet  must  be  such  as  will  furnish  an  abundance 
of  waste  matter  in  the  intestine,  and  should  therefore  be  rich 
in  cellulose  and  of  such  a  character  as  will  mechanically 
stimulate  the  mucosa.  In  arranging  the  dietary  for  such 
patients,  cold  drinks  should  be  included,  such  as  a  glass  of 
cold  water  upon  arising  in  the  morning,  soda  water,  Apolli- 
naris,  etc.,  with  or  without  fruit-juices,  such  as  raspberry, 
lemon,  etc.;  also  tea  and  malted  coffees  (bean  coffee  being 
excluded),  buttermilk,  sour  milk,  sugar  of  milk,  koumiss 
(twice  daily),  butter,  all  kinds  of  fruits  and  vegetables  in  every 
form, — cooked  or  raw, — legumes,  pumpernickel,  honey-cakes, 
and  meats  of  all  kinds,  but  in  limited  amounts;  the  only 
wines  allowed  should  be  the  white  varieties,  such  as  Moselle, 
Rhine,  or  White  Bordeaux,  Hautes  Sauternes,  etc. 

Constipating  foods,— such  as  red  wines,  cocoa,  cereal  soups, 
rice,  grits,  sago,  etc., — are  contraindicated.  For  full  details, 
the  reader  is  referred  to  the  special  diet-tables  in  the  Appendix. 

Medicaments. — Only  in  cases  in  which  chronic  constipa- 
tion is  not  the  primary  trouble,  but  only  a  symptom  of  some 
other  disease  of  the  intestine,  stomach,  or  other  organs  of  the 
body,  may  the  patient  be  allowed  to  avoid  a  severe  dietetic 
regime  and  resort  to  the  use  of  laxatives.  Such  is  the  case  in 
arteriosclerosis,  diseases  of  the  heart,  kidney  affections, 
marked  obesity,  diabetes,  and  especially  in  habitus  apojjlecticus, 
diseases  of  the  female  genital  organs,  and  naturally  also  in 
chronic  appendicitis  and  stenosis  of  the  intestine. 

For  temporary  rehef,  the  most  suitable  remedies  are 
castor  oil  in  doses  of  two  or  three  tablespoonfuls  or  8  or  10 
capsules,  in  a  glass  of  one  of  the  laxative  mineral  waters,  or  a 
teaspoonful  of  Carlsbad  salts  dissolved  in  a  glass  of  lukewarm 
water,  to  be  taken  on  the  empty  stomach. 


DISEASES  OF  THE  INTESTINE  311 

The  following  preparations  are  the  most  desirable  lax- 
atives for  extended  use: 

1.  Grillon's  or  Kanoldt's  tamarind  tablets,  I-  to.  1  tablet 

in  the  evening. 

2.  Wine  of  cascara  sagrada,  one  or  two  teaspoonfuls  in 

the  evening. 

3.  Compound  licorice  powder,  |  to  1  teaspoonful  in  the 

evening. 

4.  Rhubarb  tablets,  each  containing  0.5  [gr.  viiss],  in  the 

evening. 

5.  St.    Germain    tea,    1   tablespoonful  to   a   cup    of    hot 

water,  in  the  evening. 

6.  Cortex  frangulse,  1  tablespoonful  in  a  cup  of  water  in 

the  evening. 

7.  Cascara  tablets. 

8.  Marienbad  and  Schweizer  pills. 

9.  Extract  of  rhubarb  10.0  [oiiss],  sodium  sulphate  20.0 

[5v],  and  bicarbonate  of  soda  20.0  [5v],  taken  in  J 
to  1  teaspoonful  doses  in  the  evening. 

10.  As  alternatives:   Purgen,  exodin,  regulin,  etc. 

For  acute  cases,  aloes  and  jalap  may  also  be  recommended. 

Spastic  Stage  of  Constipation. — -The  treatment  of  this 
form  of  constipation  is  essentially  different  from  that  of  the 
above,  for  the  reason  that  in  addition  to  the  constipation, 
the  membranous  enteritis  and  mucous  colic  must  also  be  simul- 
taneously treated.  The  cases  associated  with  mucous  or  ster- 
coral diarrhoea  require  anticatarrhal  treatment. 

In  the  therapy  of  the  spastic  variety  of  constipation,  it 
must  be  kept  in  mind  that  the  intestine  is  in  an  irritable 
condition,  that  the  mucous  membrane  is  inflamed,  and  that 
the  intestinal  musculature  is  in  a  state  of  hypertonicity. 

Hygiene. — ^As  much  rest  as  possible  should  be  prescribed, 
especially  after  eating.  In  severe  cases,  especially  in  neuro- 
pathically-inclined  individuals,  two  or  three  weeks'  rest  in 
bed, — preferably  in  a  sanitarium, — is  absolutely  essential  if  the 
patient  is  unable  to  secure  the  necessary  rest  at  home.    Natur- 


312  DISEASES  OF  THE  DIGESTIVE  CANAL 

all}',  this  requires  freedom  from  all  worry  and  anxiety, — other- 
wise favorable  results  will  not  be  obtained  from  the  treatment. 

Mechanical  Treatment.  —  Massage  is  contraindicated,  be- 
cause its  use  would  aggravate  the  spasmodic  contraction  of  the 
colon.  The  abdomen  should  be  kept  warm  by  woolen  ban- 
dages, while  abdominal  supports  are  necessary  only  in  cases 
associated  with  enteroptosis  or  "hang-belly." 

In  this  stage,  Fleincr's  oil-treatment  is  of  great  value. 

My  usual  procedure  is  to  introduce  300  to  400  c.c.  of 
sesame  or  olive  oil,  at  body-temperature,  into  the  rectum 
about  10  o'clock  in  the  evening,  just  before  the  patient  retires. 
The  patient  should  assume  the  left-side  position,  and  the  oil 
should  be  allowed  to  enter  the  bowel  slowly  through  a  Naunyn's 
rectal-tube  connected  with  a  glass  funnel.  After  the  intro- 
duction of  the  oil,  the  patient  should  lie  on  the  abdomen  for 
about  a  quarter  of  an  hour.  The  introduction  of  oil  into  the 
rectum  with  an  ordinary  hard  rubber  syringe  is  ineffective, 
since  the  oil  does  not  reach  high  enough.  The  physician 
should  never  neglect  to  advise  the  patient  to  protect  the  bed 
from  becoming  soiled  by  the  treatment,  since  otherwise, 
because  of  its  uncleanliness,  he  might  become  disgusted  and 
refuse  to  carry  it  out.  The  oil  should  be  retained  in  the  intes- 
tine at  least  until  the  following  morning. 

In  the  beginning  of  treatment,  oil  should  be  introduced 
every  other  day;  and  later,  every  third  day.  I  generally 
instruct  patients  to  omit  the  treatment  on  those  days  when 
there  has  been  a  spontaneous  evacuation  of  the  stool,  and 
to  resort  to  its  use  again  in  the  evening  of  the  first  day  when 
the  bowels  have  not  moved. 

The  oil  dissolves  the  hard  scybala  which  have  remained 
in  the  folds  of  the  colon,  often  for  several  days,  and  which 
have  maintained  the  spasm  of  the  musculature.  In  addition 
to  this,  the  oil  is  decomposed  into  fatt}^  acids,  which  excite 
peristalsis  and  produce  both  mechanical  and  chemical  stim- 
ulation of  the  bowels. 

Hydrotherapy. — Cold  procedures  are  contraindicated.  To 
benefit  the   general   neurasthenical   condition,   I   advise   pro- 


DISEASES  OF  THE  INTESTINE  313 

tracted  lukewarm  baths,  at  a  temperature  of  about  25°  to 
30°  R.  [88°-100°  F.],  lasting  about  I  hour;  or  the  pine-needle 
baths,  containing  {  litre  of  the  extract  in  each  bath;  besides 
moist,  warm  abdominal  bandages,  consisting  of  a  wet  towel 
covered  first  by  oiled  paper  or  oiled  silk,  then  by  a  woolen 
bandage,  and  worn  during  the  night. 

Diet. — -In  contraindication  to  the  coarse  constipation- 
diet  indicated  in  the  atonic  form,  the  mild  constipation-diet 
should  be  used  in  this  stage  of  the  disease,  for  the  reason  that 
the  coarse  foods,  rich  in  cellulose,  would  aggravate  the  spasm 
of  the  colon,  and  might  easily  cause  secondary  membranous 
enteritis  of  the  intestine,  or  give  rise  to  very  frequent  or 
persistent  diarrhoea. 

The  mild  constipation-diet  consists  of  the  following:  Tea,  malted 
coffee,  and  fruit-juices,  which  should  never  be  taken  cold;  milk,  white  wines, 
white  Bordeaux, — such  as  Hautes  Sauternes, — cream,  koumiss,  buttermilk, 
sour  milk,  soft  cheese,  and  a  tablespoonful  of  sugar-of-milk  three  times 
daily  dissolved  in  liquid  foods ;  only  light  vegetables, — such  as  peas,  carrots, 
asparagus,  cauliflower,  spinach,  and  Brussels  sprouts,  chestnuts  and  pota- 
toes,— all  to  be  served  in  the  puree  form.  The  patient  should  eat  freely  of 
sweet  fruit-sauces,  honey,  and  marmalades  made  from  the  raspberry,  orange, 
plum,  grape,  apple,  date,  etc. 

The  diet  in  spastic  constipation  should  stimulate  peristalsis 
chemically;    in   atonic    constipation,    mechanically. 

The  following  foods  should  be  forbidden:  Coarse  breads, 
acids,  sour  fruits,  flatuous  vegetables, — such  as  cabbage,  peas 
and  beans, — red  wine,  goose,  duck,  eel,  salmon,  and  sardines 
in  oil. 

Balneological  Treatment. — Treatment  at  a  mineral-water 
resort  need  be  considered  only  in  severe  cases  of  spastic 
constipation. 

Before  sending  a  patient  to  such  a  place,  it  is  advisable 
to  examine  the  gastric  contents  by  means  of  a  test-breakfast, 
in  order  to  determine  whether  hydrochloric  acid  is  secreted  in 
normal,  diminished,  or  increased  amounts. 

When  the  hydrochloric  secretion  is  normal  or  increased  in 
spastic  constipation,  with  a  secondary  membranous  enteritis 
and  gas  or  mucous  colic,  I  send  the  patients  to  Carlsbad,  Fran- 


314  DISEASES  OF  THE  DIGESTIVE  CANAL 

zensbad,  Ncucnahr,  or  Vichy,  where  they  (h'ink  the  thermal 
watcTS  and  have  the  hot  mud-poultiecs  apphed  to  the  abdomen. 

AVhcn  hydrochloric  acid  is  diminished  or  absent,  such 
patients  should  be  sent  to  Kissingen,  Homburg,  or  Wiesbaden. 
The  details  of  treatment  should  be  directed  by  the  attending 
phj'sician  at  the  watering-place. 

Medicinal  Treatment.  —  Purgatives  are  contraindicatcd, 
because  they  are  very  often  the  cause  of  the  trouble,  because 
they  increase  the  secondary  catarrh  of  the  intestine,  and 
because  they  are  effective  only  in  very  large  doses. 

Sedatives,  on  the  contrary,  just  as  in  lead  colic,  are 
indicated  as  in  the  following  prescriptions: 

1.  I^     Extract!  belladonnse  foliorum,  gr.  ivss-vij     0..3-0.5 
M.  ft.  pil.  No.  XXX.     Sig. — One  pill  after  meals,  t.i.d.,  in 

simple  spastic  constipation  witli  gas  and  mucous  colic. 

2.  I^     Tincturse  belladonnge  foliorum,  gtt.  Ixxx-oiiss  5.0-10.0 

Spiritus  menthse  piperitiE,  gtt.  Ixxx  5.0 

Tincturse  valerianse,  5iv-ov  15.0-20.0 

M.  Sig. — Thirty  drops  in  a  cup  of  hot  carminative  tea,  t.i.d. 

3.  1^     Extracti  belladonnge  foliorum,  gr.  ivss-viiss     0.3-0.5 

Extracti  opii,  gr.  vi-xii  0.4-0.8 

M.  ft.  pil.  No.  XXX.     Sig. — One  pill  t.i.d.  for  very- 
nervous  patients. 

4.  I^     Extracti  belladonnge  foliorum,  gr.  ivss  0.3 

Spiritus  menthce  piperitse,  gtt.  xv  1.0 

Tincturse  valerianse,  oi  30.0 

M.  Sig. — Twenty-five  drops  t.i.d. 

A  cup  of  carminative  tea,  as  hot  as  possible,  taken  morn- 
ing and  evening  for  several  months  is  very  helpful.  One 
tablespoonful  of  equal  parts  of  valerian,  peppermint,  fennel 
and  caraway,  steeped  in  a  cup  of  hot  water,  is  a  very  suitable 
preparation.  A  glass  of  hot  water  taken  night  and  morning 
also  tends  to  relax  the  spasm  of  the  bowels. 

For  patients  who  suffer  very  severely  from  colic,  and  for 
those  who  travel,  I  prescribe  a  compressed  tablet  of  atropine 
sulphate  containing  0.0005  [yj-^  gr.],  twice  daily  after  eating, 
the  temporary  use  of  which  is  not  injurious. 

Morphine  should  not  be  prescribed  in  these  cases. 


DISEASES  OF  THE  INTESTINE  315 

PROGNOSIS  AND  COURSE 

Successful  results  are  obtained  in  most  cases,  the  patient 
being  permanently  cured,  or  at  least  remaining  well  for  a 
number  of  years.  I  have  obtained  the  least  satisfactory 
results  in  treating  persons  who  were  excessively  obese,  or  very 
nervous,  or  in  the  case  of  women  in  the  climacterium. 

Very  successful  results  are  quickly  obtained  from  diet 
and  massage,  in  enteroptotic  and  under-nourished  patients 
suffering  from  the  atonic  form  of  constipation.  It  is  very 
frequently  the  case,  that  after  the  first  week  of  treatment 
their  bowels  become  normal. 

Cases  of  spastic  constipation  are  more  difficult  to  treat, 
for  the  reason  that,  in  addition  to  the  constipation,  there  is 
the  catarrhal  factor  to  combat,  as  well  as  the  injcreased  reflex- 
ibility  of  the  nervous  system.  I  have,  however,  obtained 
most  satisfactory  results, — even  after  constipation  had  existed 
for  fifteen  years  or  more, — through  rest,  hot  apphcations, 
belladonna,  oil  enemata,  and  a  suitable  mild  constipation-diet. 

It  is  particularly  necessary  in  this  disease  to  individualize 
in  the  selection  of  the  proper  therapy.  Until  the  physician's 
experience  is  large,  it  is  well  for  him  to  follow  the  above- 
mentioned  differential  diagnostic  principles,  namely: 

Constipation  without  pain  indicates 
atonic  constipation;  constipation  asso- 
ciated with  gas  and  mucous  colic  indicates 
spastic   constipation. 

The  therapy  directed  according  to  the  above  will  usually 
be  correct. 

To  treat  atonic  cases  with  oil  enemata  is  superfluous;  and 
to  treat  spastic  constipation  with  a  coarse  constipation-diet 
is  an  error,  since  it  would  aggravate  the  associated  catarrhal 
condition   of  the   mucosa. 

PROPHYLAXIS 

Only  the  family  physician,  who  knows  accurately  the 
pathogenesis,  the  symptoms,  and  the  course  of  the  disease  in 
the  individual,  is  in  a  position  to  prevent  the  later  stages  by 


316  DISEASES  OF  THE  DIGESTIVE  CANAL 

the  timely  institution  of  suital)l('  theraiKnitic  measures.  For 
instance,  in  enteroptotic  in(li^•i(l^lals  he  can  prescribe  a  suf- 
ficientl}^  iiourishing  diet,  exercise,  fresh  air,  and  a  yearly 
outing  and  vacation. 

CLOSING    REMARKS 

There  are  few  diseases  so  strikingly  the  result  of  our 
over-refined  civilization,  and  directly  attributable  to  insuf- 
ficient exercise,  diet  containing  too  little  waste  matter,  loss 
of  appetite,  and  disturbances  of  the  stomach,  as  chronic 
constipation. 

It  would  be  interesting  to  know  whether  this  disease  is  as 
widely  prevalent  among  the  wild  tribes  who  subsist  largely  on 
raw  foods.     It  may  safely  be  assumed  that  such  is  not  the  ca.se. 

CLINICAL    CASES 
1.  Atonic  Constipation 

Case  1. — Minnie  F.,  45  years  old,  had  been  constipated  from  15  to  20 
years  and  had  used  all  kinds  of  laxatives,  which  had  lately  been  ineffective, 
unless  taken  in  very  large  doses.  She  Jiad  suffered  no  pain,  but  had  expe- 
rienced lassitude  and  loss  of  appetite.  The  physical  examination  was 
negative.  The  patient  had  a  normal  habitus.  The  treatment  consisted  of 
massage,  a  coarse  constipation-diet  and  faradization.  After  two  weeks,  the 
stools  became  normal  and  remained  so  for  the  five  years  the  patient 
was  under  observation;  and  during  this  time  she  increased  15  or  20 
pounds  in  weight. 

Case  2. — Clara  B.,  30  years  old,  had  for  ten  years  been  unable  to 
obtain  any  action  of  the  bowels  by  natural  means,  always  having  resorted 
to  laxatives  or  enemata.  For  one  year  the  patient  had  complained  of  pres- 
sure in  the  epigastrirmi  after  eating,  for  relief  of  which  she  sought  treatment 
at  the  polyclinic.  The  patient  had  never  suffered  from  pain  in  the  abdomen. 
Examination  showed  her  to  be  enterojDtotic,  and  suffering  from  emaciation 
and  anaemia.  Otherwise  the  findings  were  negative.  The  patient  was 
prescribed  a  heavy  fattening-constipation  diet,  bitters  and  massage.  After 
eight  daj^s  the  stools  became  normal.  The  patient  afterward  gained  12  or 
15  pounds  in  weight  and  remained  permanently  well. 

Case  3. — Mrs.  H.  W.,  38  years  old,  had  not  had  a  spontaneous  evac- 
uation of  the  bowels  for  10  or  12  years.  The  abdomen  was  large  and  pen- 
dulous. After  two  or  three  weeks  of  treatment,  the  patient  wa  spermanently 
cured,  since  which  time  she  has  increased  considerably  in  weight. 


DISEASES  OF  THE  INTESTINE  317 

2.  Spastic  Constipation 

Case  1. — Mrs.  O.  S.,  40  years  old,  had  been  constipated  for  15  or  20 
years,  during  the  early  part  of  which  period  she  had  never  had  abdominal 
pains.  For  the  past  several  years  she  had  suffered  from  colicky  pains,  vomit- 
ing, and  the  evacuation  of  mucus  and  gases  from  the  bowel.  The  patient 
alleged  that  on  several  occasions  she  had  had  stercoraceous  vomiting,  and 
that  she  was  sent  to  the  hospital  for  operation  for  ileus,  should  the  latter 
become  necessary.  At  this  time  laxatives  were  effective  only  when  given 
in  very  large  doses,  and  then  accompanied  by  violent  colicky  pains.  Enem- 
ata  were  unsatisfactorj^  The  patient  was  very  anaemic  and  emaciated, 
and  there  was  a  marked  gastroptosis.  In  palpation,  the  colon  was  of  the 
size  of  the  little  finger,  and  very  sensitive.  The  bowel-movements  consisted 
either  solely  of  membranous  mucus,  or  of  mucus  admixed  with  faeces,  of  the 
caliber  of  a  lead-pencil.  Treatment  consisted  of  the  administration  of  oil 
enemata,  at  first  every  third  day,  and  later  less  frequently,  continued  for 
three  or  four  months.  0.015  [i  gr.]  of  the  extract  of  belladonna  was  given 
three  times  daily  and  a  mild  constipation-diet  used.  The  patient  was  under 
observation  for  three  or  four  years,  during  which  time  she  remained 
entirely  well. 

Case  2. — Mrs.  Emily  P.,  55  years  old,  had  had  a  laparotomy 
performed,  twelve  years  previously,  since  which  time  she  had  been  con- 
tinuously constipated.  For  the  past  four  or  five  years,  the  patient  had 
passed  much  mucus  from  the  bowels,  and  suffered  a  great  deal  from 
"wind  colic."  She  was  permanently  cured  by  the  treatment  outlined  in 
the  previous   case. 

Case  3. — A  coachman  50  years  old  had  suffered  for  years  from  slug- 
gishness of  the  bowels,  being  obliged  to  resort  to  the  use  of  laxatives  very 
frequently.  After  errors  in  diet, — such  as  eating  cucumbers  and  heavy 
cheese, — the  patient  always  suffered  from  violent  colic.  After  treatment 
for  two  weeks, — consisting  of  rest  in  bed,  hot  applications,  oil  enemata,  and 
the  mild  constipation-diet, — the  patient  was  permanently  cured. 

3.  Mucous  Colic 

Case  1. — Mrs.  Clara  B.,  30  years  old,  had  for  several  years  suffered 
from  constipation ;  and  for  one  or  two  years,  from  mucous  colic  and  periods 
of  mucous  diarrhoea.  The  latter  would  continue  about  eight  days,  when  it 
would  be  succeeded  by  about  one  week  of  complete  constipation.  The 
patient  was  an  hysterical  subject.  Enormous  quantities  of  mucus  and 
epithelial  cells  were  mixed  with  the  faeces,  and  the  stools  had  a  caliber  about 
that  of  a  lead-pencil.  Treatment  with  atropine  gaA'e  some  relief,  but 
the  patient  was  not  cured.  Temporary  improvement  followed  residence 
in  the  country. 


318  DISEASES  OF  THE  DIGESTIVE  CANAL 

APPENDIX 

The  Relationship  between  Constipation  and  Diarrha'a 
Although  constipation  and  diarrhoea  appear  to  be  two 
diametrically  opposed  symptoms,  they  are  sometimes  observed 
either  simultaneously  in  the  same  individual,  or  the  one  fol- 
lowing the  other, — which  will  not  seem  paradoxical  to  the 
careful  reader  of  the  previous  chapter.  For  a  clear  and  correct 
understanding  of  the  relationship  between  the  two,  however, 
a  few  remarks  should  be  made. 

The  factor  by  which  both  constipation  and  diarrhoea  are 
associated  in  the  same  individual  is  a  chronic  catarrhal  condition 
of  the  colon. 

Colitis  of  a  mild  degree  runs  a  course  with  constipation, 
as  a  result  of  hypcrtonicity  of  the  musculature  of  the  bowels, 
caused  by  an  irritation  of  the  mucosa.  If,  at  this  time,  any 
such  factors  as  indigestion,  exposure  to  cold,  or  irritation 
caused  by  the  stasis  of  faeces  in  the  bowels  appear,  the  in- 
flammation of  the  mucosa  is  increased,  which  causes  diarrhoea. 

I  have  had  under  observation  a  business  man  40  years  old,  who  was 
treated  for  acid  gastritis  and  a  mild  catarrh  of  the  small  and  large  intestines. 
When  the  patient  was  on  a  non-irritating  diet,  two  or  three  stools  partly- 
formed  and  partly  of  semi-solid  consistency  were  passed  daily.  Whenever 
the  patient  indulged  in  errors  in  diet,  such  as  over-loading  the  stomach,  the 
use  of  acids,  or  eating  fried  potatoes,  etc.,  there  was  constipation  for  two  or 
three  days,  associated  with  meteorism;  while  after  gross  errors  in  diet, — 
such  as  the  free  use  of  cold  beer, — gnawing,  stabbing  pains  immediately 
appeared  in  the  abdomen,  accompanied  with  diarrhoea. 

Another  patient,  a  manufacturer,  54  years  old,  who  suffered  from 
achylia  and  intestinal  catarrh,  was  ordinarily  constipated.  Profuse  diarrhoea 
always  occurred  immediately  after  eating  food  containing  coarse  meat-fibres. 

In  ileocsecal  catarrh,  the  alternation  of  constipation  and 
diarrhoea  is  the  rule. 

In  spastic  constipation  with  membranous  enteritis,  a 
period  of  four  to  six  weeks  of  constipation  is  frequently  fol- 
lowed by  an  attack  of  mucous  diarrhoea. 

In  chronic  intestinal  catarrh  associated  with  diarrhoea, 
a  period  of  total  constipation  often  follows  an  improvement 
in  the  former  condition. 


DISEASES  OF  THE  INTESTINE  819 

Stercoral  diarrhoea  occurring  in  the  course  of  habitual 
constipation  has  already  been  mentioned,  and  is  well  known 
to  every  practitioner. 

Diarrhoea  alternating  with  constipation  can  scarcely  be 
caused  by  purely  nervous  influences.  An  exception  to  this 
condition  may  perhaps  be  mentioned  here,  namely,  the  intes- 
tinal symptoms  which  occur  in  exophthalmic  goitre. 

Naturally,  patients  suffering  from  paradoxical  symptoms 
should  receive  anticatarrhal  treatment,  consideration  and 
attention  being  given  at  the  same  time  to  the  irritabihty  of 
the  sympathetic  nervous  system  usually  present  in  these  cases. 

Neuroses  of  the  Intestine 

When  compared  with  gastric  neuroses,  purely  nervous 
affections  of  the  intestine  are  relatively  less  frequent,  if  we 
except  habitual  constipation,  the  nature  of  which  has  been 
described  in  detail  in  the  foregoing  chapters.  In  an  affection 
which,  in  individual  cases,  is  greatly  modified  by  the  irrita- 
bility or  weakness  of  the  intestinal  nerves,  the  nervous  factor 
often  determines  whether  the  constipation  will  assume  the 
atonic  or  the  spastic  form. 

In  a  neurasthenical  or  hysterical  individual  suffering 
from  an  intestinal  neurosis,  a  great  variety  of  symptoms 
in  the  mesogastrium  and  hypogastrium  are  complained  of. 
It  is  an  interesting  fact,  however,  that  an  accurate  exam- 
ination of  the  faeces  will  reveal  the  presence  of  an  anatomical 
lesion,  usually  of  a  catarrhal  nature,  in  the  majority  of  these 
cases.  As  a  further  proof  that  these  cases  are  due  to  organic 
alterations  of  the  mucosa  rather  than  to  neuroses,  the  fact 
may  be  mentioned  that  such  patients  improve  if  given  a 
treatment  adapted  to  an  organic  affection,  while  no  improve- 
ment of  the  symptoms  results  from  purely  antinervous 
treatment. 

It  seems  certain,  at  the  present  time,  that  such  conditions 
as  arteriosclerosis  and  syphilis  also  play  a  causative  role  in  the 
production  of  many  of  these  vague  disturbances  in  the  abdo- 
men, which  were  formerly  considered  as  of  nervous  origin.    Our 


320  DISEASES  OF  THE  DIGESTIVE  CANAL 

present  methods  of  investigation,  however,  are  too  imperfect 
to  inform  us  fully  as  to  the  exact  anatomical  changes  present. 

The  phj'sician  must,  for  these  reasons,  use  the  greatest 
caution  in  making  a  diagnosis  of  a  neurosis  of  the  intestine, 
and  should  arrive  at  such  a  conclusion  only  when,  (1)  all 
evidences  of  an  organic  disease  are  absent,  and  (2)  when  in 
any  given  case  the  symptoms  are  not  influenced  in  any  way 
b}"  dietetic  treatment;  while,  on  the  other  hand,  depending 
upon  the  condition  of  the  nervous  system,  the  patient's  con- 
dition is  better  or  worse. 

It  is  self-evident  that  a  neuropathic  individual  with 
markedly  increased  reflex  irritability  will  react  more  strongly 
to  slight  pathological  irritations  than  an  individual  with  a 
stable  nervous  organization. 

Also  the  fact  that  habitus  enteropticus,  which  has  already 
been  frequently  mentioned,  is  of  considerable  importance  in 
the  diagnosis  of  intestinal  conditions,  need  not  be  especially 
emphasized. 

It  is  a  fact  that  severe  enterocolitis,  with  its  unpleasant 
symptoms  of  flatulence,  meteorism,  colic,  etc.,  is  observed 
with  especial  frequency  in  enteroptotic  and  neurasthenical 
individuals.  That  in  such  cases  we  have  an  organic  disease 
of  the  intestinal  mucosa  to  deal  with  is  proven  by  the  presence 
of  mucus  in  the  fseces  in  most  of  these  cases.  One  may  even 
go  a  step  further,  and  maintain  that  a  great  number  of  the 
nervous  symptoms  are  dependent  upon  the  organic  affection 
of  the  bowels,  the  treatment  and  removal  of  which  almost 
always  cause  a  complete  disappearance  or  an  amelioration  of 
the  nervous  symptoms. 

The  diagnosis  of  ''nervous  diarrhoea"  is  often  erroneously 
made  along  the  same  line.  This  is  an  extraordinarily  rare 
affection;  in  by  far  the  majority  of  cases  we  have  to  do  rather 
with  a  combination  of  neurasthenia  and  intestinal  catarrh. 

The  intestinal  neuroses  may  be  conveniently  divided 
into:    (a)  motor,  (6),  sensory;    and  (c),  secretory. 

From  the  practical  standpoint,  only  the  following  are 
of  importance  and  significance: 


DISEASES  OF  THE  INTESTINE  321 

Atony  of  the  Intestine. — We  have  considered  chronic 
atony  in  the  chapter  on  Habitual  Constipation;  and  the  acute 
weakness  of  the  intestine,  in  the  chapter  on  Intestinal  Ob- 
struction. The  latter  occurs  primarily  only  in  either  marked 
congenital  or  acquired  enteroptosis,  and  secondarily  after 
trauma,  laparotomy,  peritonitis  or  shock,  which  cause  acute 
paralysis  of  the  intestine. 

The  diagnosis  of  acute  intestinal  paralysis,  or  the  so- 
called  paralytic  ileus,  is  made  from  the  absence  of  violent 
pain,  fever,  and  intestinal  ''stiffenings." 

Chronic  intestinal  atony  is  identical  with  atonic  consti- 
pation, the  diagnosis  and  therapy  of  which  have  already  been 
discussed. 

The  therapy  of  the  acute  form  consists  in  the  adminis- 
tration of  laxatives  and  in  high  irrigations  of  the  colon. 

The  following  combination  is  the  most  suitable  for  use 
in  the  latter: 

Castor  Oil,  2  tablespoonfuls; 
Cod-Liver  Oil,  1  tablespoonful; 
Bicarbonate  of  Soda,  J  teaspoonful; 
Warm  Water,  1  to  2  litres. 

The  above  should  be  well  emulsified  and  introduced  with 
the  patient  in  the  knee-elbow  position. 

The  best  laxatives  are  castor  oil,  laxative  mineral  waters, 
rhubarb,  and  jalap. 

Intestinal  Spasms. — Spasm  as  an  intestinal  neurosis  is 
extremely  rare;  much  more  frequently  we  find  a  catarrhal 
condition  associated  with  it,  as  evidenced  by  the  presence  of 
mucus  in  the  stools,  and  the  occurrence  of  diarrhoea  after 
errors  in  diet,  taking  cold,  etc.  I  wish  to  emphasize  again, 
as  has  already  been  mentioned  in  the  chapter  on  Constipation, 
that  in  nervous  individuals  an  enterocolitis  will  produce  a 
contraction  of  the  intestinal  musculature  earlier  than  in  non- 
nervous  persons. 

Symptoms. — Patients  have  a  feeling  of  pressure  or  tension 
across  the  abdomen,  similar  to  the  "girdle-sj^mptom"  of 
locomotor  ataxia,  in  consequence  of  spasm  of  the  transverse 

21 


32^2  DISEASES  OF  THE  DIGESTIVE  CANAL 

colon.  This  spasm  is  usually  associated  with  frequent  colicky, 
cutting,  and  sometimes  cramp-like  pains  around  the  umbilicus, 
generally  radiating  from  right  to  loft,  lasting  a  few  minutes, 
and  disappearing  after  the  escape  of  gas.  By  palpation,  the 
colon,  and  cspcciall}'  the  transverse  colon  and  the  sigmoid 
flexure,  will  be  found  to  resemble  a  hard  cord  or  band  about 
the  size  of  the  little  finger,  and  sensitive  to  pressure. 

Intestinal  obstruction,  or  the  so-called  spastic  ileus,  may 
result  from  a  very  severe  spasm  of  the  intestinal  musculature 
(see  below). 

Treatment.— Since  intestinal  spasm  is  usually  a  symptom 
of  intestinal  catarrh,  the  latter  should  alwa3^s  be  treated  as 
the  primary  condition;  although  sedatives  and  antispas- 
modics, such  as  bromide  and  belladonna,  are  indicated,  from 
the  fact  that  the  spasmodic  feature  is  more  frequent  in 
hysterical  and  neurasthenical  subjects. 

1.  I^     Potassii  bromidi,  oi     30.0 

Sig. — A  knifepoint  in  milk  or  water  night  and  morning. 

2.  I^     Extracti  belladonna;  foliorum,  gr.  J-J     0.01-0.02 
Ft.  pil.  or  chart,  i,  No.  xii.    Sig. — One  t.i.d. 

3.  I^     Extracti  opii,  gr.  J-i     0.02-0.03 
M.  ft.  pil.  i,  No.  xii.     Sig. — One  t.i.d. 

The  dietetic,  balneological  and  hydropathic  treatment  is 
the  same  as  in  mild  enterocolitis  associated  with  constipation. 

The  patient  should,  therefore,  be  put  on  a  light  consti- 
pation-diet and  Wiesbaden  or  Vichy  mineral  water,  and  the 
use  of  mud-poultices  applied  to  the  abdomen,  and  a  Priessnitz 
bandage  at  night.  Nervous  patients  should  be  given  Carlsbad 
water, — which  contains  Glauber's  salt, — with  caution,  and 
then  only  in  small  doses. 

Lend  Colic. — Lead  colic  is  the  result  of  an  actual  spasm  of  the  intes- 
tinal musculature,  occurring  in  painters,  plumbers,  boxmakers,  etc. 

A  diagnosis  of  the  condition  is  very  readily  made  if  constipation  asso- 
ciated with  colicky  pains  occurs  in  one  engaged  in  any  of  these  occupations. 
Patients  with  lead  colic  have  usually  passed  dry  hard  stools  of  very  small 
caliber  for  a  long  time,  until  they  have  finally  become  completely  constipated. 
Severe  mesogastralgia  occurs,  which  is  intensified  by  the  use  of  laxatives. 


DISEASES  OF  THE  INTESTINE  323 

The  intestine  is  contracted  and  the  blue  line  on  the  gums  is  usually 
demonstrable,  or  at  least  the  anamnesis  generally  shows  that  the  patient  is 
engaged  in  some  occupation  in  which  he  comes  into  contact  with  lead. 

The  treatment  of  lead  colic  consists  in  the  use  of  hot  compresses,  oil 
enemata,  or  0.06  [gr.  i]  of  the  extract  of  opium  three  or  four  times  daily,  and 
the  later  use  of  potassium  iodide  and  sulphur  baths. 

Nervous  Diarrhcea. — Acute  nervous  diarrhoea  is  the  result 
of  greatly  increased  peristalsis,  caused  by  intense  emotional 
excitement,  especially  fright.  At  first  the  stools  are  formed, 
and  later  they  consist  only  of  watery  evacuations  in  which 
almost  the  entire  contents  of  the  bowels  may  be  expelled  in 
from  half  an  hour  to  an  hour,  without  any  evidence  of  their 
being  pathological. 

Chronic  or  frequently  recurring  diarrhoea  is  hardly  ever 
of  purely  nervous  origin,  but  is  generally  associated  with  a 
catarrhal  inflammation  of  the  intestinal  mucosa,  with  the 
exception  of  the  diarrhoea  which  occurs  in  Basedow's  disease. 

Acute  nervous  diarrhoea  does  not  require  treatment, 
while  the  chronic  form  should  be  treated  with  a  catarrhal  diet 
and  catarrhal  medication.  The  catarrh  of  Basedow's  disease 
should  be  treated  in  connection  with  the  primary  disease. 

Peristaltic  Unrest  of  the  Intestine. — This  condition  is 
treated  by  various  authors  as  an  intestinal  neurosis.  I  must 
say,  however,  that  I  have  never  seen  an  undoubted  case  of 
this  sort.  The  peristalsis  of  the  small  intestine,  which  is  so 
frequently  seen  in  women  with  pendulous  abdomen  or  with 
broad  diastases  of  the  recti  muscles,  is  normal;  on  the  other 
hand,  the  so-called  intestinal  "stiffenings,"  considered  by 
Nothnagel  as  a  symptom  of  stenosis  or  obstruction  of  the 
intestine,  are  pathological.  Borborygmus  is  a  sign  of  abnormal 
fermentation  of  food  in  catarrh  of  the  small  and  large  intestines. 

From  the  practical  standpoint,  peristaltic  unrest  of  the 
intestine  is  of  no  importance. 

Flatulence  and  Meteorism. — I  have  already  shown  that 
these  conditions  are  symptoms  of  enterocolitis.  The  fact  that 
they  occur  very  frequently  in  hysterical  persons  is  no  evidence 
that  the  affection  is  not  of  a  catarrhal  nature.     They  are 


324  DISEASES  OF  THE  DIGESTIVE  CANAL 

frequent  in  nervous  women  with  cntcroptosis  who  have 
suffered,  from  habitual  constipation  for  a  number  of  years, 
which  in  turn  has  caused  a  sccontlary  membranous  enteritis 
and  a  spasmodic  condition  of  the  colon.  It  is  cjuite  clear 
that,  through  a  rapidly  developing  spasm  of  the  colon, 
stagnation  of  the  fluid  faeces  occurs,  which  gives  rise  to 
meteorism. 

Membranous  Enteritis. — This  condition,  which  is  still 
regarded  by  some  authors  as  an  intestinal  neurosis,  must  be 
considered  at  the  present  time  as  merely  a  colitis  secondary 
to  habitual  constipation. 

Mucous  colic  is  an  acute  exacerbation  of  a  chronic  colitis. 

The  same  relation  exists  between  chronic  colitis  and 
m.ucous  colic  as  between  cholecystitis  and  gall-stone  colic. 

For  further  details  concerning  membranous  enteritis, 
the  reader  is  referred  to  the  special  chapter  on  Chronic 
Constipation. 

Intestinal  Neurasthenia. — In  this  condition  it  is  more 
accurate  to  speak  of  the  neurasthenia  which  occurs  in  patients 
suffering  from  intestinal  affections.  The  subject  requires  a 
special  consideration. 

Hypochondriasis  and  melancholia  are  accompanying 
phenomena  in  many  cases  of  chronic  constipation.  Such 
patients  have  their  minds  continually  upon  their  intestinal 
functions,  anxiously  and  accurately  noting  all  symptoms, 
almost  despairing  if  the  chosen  purgative  does  not  produce 
the  expected  results,  etc.,  etc.  Actual  psychoses  may  develop 
in  this  way,  which  may  even  lead  to  suicide. 

If  constipation  has  already  existed  for  several  years  and 
has  led  to  enterocolitis,  or  to  its  incipient  stage,  the  abdomi- 
nal symptoms  of  fermentation  will  cause  much  anxiety 
and  suffering.  The  patients  complain  of  tremor,  of  their 
hands'  being  hot,  of  cerebral  congestion,  a  feeling  of  heaviness 
in  the  extremities,  tension  in  the  abdomen,  lack  of  desire 
to  work,  insomnia,  anorexia,  nausea,  emaciation,  sensations  of 
fear  and  mental  depression.  These  secondary  symptoms  are 
most   frequently   associated   with  enterocolitis   which   runs   a 


DISEASES  OF  THE  INTESTINE  325 

course  with  spastic  constipation.  They  occur  more  rarely 
in  other  forms  of  the  disease,  because  the  fermenting  fiL'ces 
are  rapidly  evacuated  by  the  associated  diarrhoea. 

This  entire  symptom-complex  has  been  designated  as 
Flatulent  Intestinal   Dyspepsia. 

These  symptoms  must  be  explained  as  a  reflex  irritability 
of  the  splanchnic  nerve;  I  will  only  mention  the  fact  that 
many  authors  assume  autointoxication  as  their  cause,  and 
while  this  is  quite  possible,  it  has  not  yet  advanced  beyond 
the  stage  of  a  hypothesis. 

Treatment. — The  therapy  of  intestinal  neurasthenia  con- 
sists in  those  measures  which  will  cure  the  constipation  and 
the  resulting  flatulence.  If  the  physician  is  successful  in  doing 
this,  the  hypochondriasis  disappears  and  the  vasomotor  and 
reflex  troubles  become  considerably  better,  being  often  entirely 
relieved.  The  tendency  to  relapse,  however,  generally  remains 
in  these  cases. 

It  would  be  a  great  mistake  to  endeavor  to  cure  the 
neurasthenical  affection  solely  by  hydrotherapy,  electricity, 
massage,  etc.,  without  taking  into  consideration  the  asso- 
ciated intestinal  condition. 

INTESTINAL  DISTURBANCES  IN  DISEASES  OF  OTHER  ORGANS 

In  the  absence  of  anatomical  affections  of  the  intestine, 
the  latter  shows  much  fewer  symptoms  than  does  the  stomach, 
when  other  organs  of  the  body  are  diseased. 

The  diarrhoea  which  occurs  in  exophthalmic  goitre  and 
tabes  dorsalis  need  only  be  mentioned.  If  diarrhoea  or  intes- 
tinal hemorrhage  occurs  in  tuberculosis,  arteriosclerosis, 
cardiac  disease,  nephritis,  cirrhosis  of  the  liver,  pericarditis,  or 
diabetes,  these  are  the  result  of  secondary  catarrh  or  ulceration 
of  the  intestine, — both  of  which  have  already  been  described. 

Parasites  of  the  Intestine 

It  is  not  one  of  the  tasks  of  this  book  to  give  a  systematic 
discussion  of  the  parasites  of  the  intestine.  For  a  full  con- 
sideration of  this  subject,  the  reader  is  referred  to  the  larger 


326  DISEASES  OF  THE  DIGESTIVE  CANAL 

works  of  Hosier  and  Peipcr,  Braun,  Von  Jacksch,  etc.  Some  of 
Ihc  diagnostic  and  therapeutic  suggestions,  merely,  will  be 
given  here. 

Diagnosis. — The  subjective  symptoms  of  intestinal  para- 
sites in  children  are  nausea,  vomiting,  loss  of  appetite,  and 
itching  of  the  nose  or  anus,  particularly  at  night.  The  presence 
of  a  tapeworm,  or  of  a  large  number  of  smaller  worms,  may 
produce  colicky  pains,  although  these  are  generally  of  rare 
occurrence.  Adults  who  have  tapeworms  frequently  expe- 
rience unpleasant  sensations  after  such  foods  as  herring,  sour 
pickles,  coffee,  light  beer,  etc. 

The  above-mentioned  symptoms  are,  however,  so  un- 
certain and  are  observed  in  so  many  other  affections,  that 
the  physician  should  never  undertake  the  treatment  of  tape- 
worm without  objective  proof  of  the  presence  of  the  parasite. 

The  objective  symptoms  are  as  follows: 

The  macroscopic  demonstration  of  the  worms  them- 
selves, or  of  some  of  their  mature  segments,  or  the  micro- 
scopical demonstration  of  their  ova  or  of  Charcot-Leyden 
crystals  in  the  stool  (see  illustration,  page  250). 

The  segments  of  the  worms  are  generally  brought  to  the 
physician,  who,  in  order  to  best  examine  them,  should  press 
the  segments  out  fiat  between  two  cover-glasses  fastened  at 
both  ends. 

But  few  ramifications  of  the  uterus  will  be  observed  in 
the  tcenia  solium  of  pork;  while  a  great  many,  numbering 
from  30  to  40  on  both  sides,  are  observed  in  the  tcenia  saginata 
of  beef. 

A  person  infected  with  the  ttrnia  solium  is  in  constant 
danger  of  infecting  others,  so  that  unless  precautions  are  used, 
both  the  patient  himself  and  his  family  are  liable  to  cysticercus. 
For  this  reason,  the  differentiation  between  the  two  tape- 
worms is  of  considerable  practical  importance. 

In  children  who  are  suspected  of  having  worms,  the 
examiner  should  wipe  the  anal  mucous  membrane  with  a 
spatula  and  examine  the  specimen  microscopically,  when 
oxyurides  or  their  ova  are  frequently  found. 


DISEASES  OF  THE  INTESTINE  327 

If  nothing  is  observed  from  the  macroscopical  examina- 
tion of  the  stool,  the  latter  should  be  examined  for  ova  and 
Charcot-Leyden  crystals,  according  to  the  methods  outlined 
in  the  General  Section  on  the  Examination  of  the  Faeces. 

The  microscopical  examination  is  of  especial  value  to 
ascertain,  in  cases  of  tapeworm,  whether  the  head  has  been 
found  or  not,  as  it  is  only  by  this  means  that  the  physician 
may  anticipate  a  recurrence. 

It  should  be  mentioned  that  occasionally,  for  some 
unknown  reason,  the  ova  are  not  detected,  even  when  the 
tapeworm  is  present. 

If  the  examiner  does  not  have  access  to  a  microscope, 
and  desires  to  assure  himself  whether  or  not  a  worm  is  present, 
he  should  administer  castor  oil  or  worm-lozenges  before  insti- 
tuting the  actual  cure. 

TREATMENT 

1.'  The  Smaller  Worms,  such  as  Ascarides,  Oxyurides,  etc. — 
The  most  certain  vermifuge  is  santonin,  which  should  be  given 
alone  in  troches,  or  in  powder  form  combined  with  calomel, 
as  in  the  following  prescriptions: 

1.  I^     Santonini, 

Calomel,  iia,  gr.  ^-iss,     0.03-0.1 
Saccharianin,  q.s. 

M.    ft.  pulv.  Dos.  vi.     Sig. — A  powder  night 
and  morning. 

2.  I^     Olei  chenopodii, 

Mucilaginis  acacise,  aa,  gtt.  xc 
Aquae  destillatae, 

Syxupi  aurantii  corticis,  aa,  gtt.  xc 
M.    ft.  emulsio.    Sig. — One-half  teaspoonful  t.i.d. 

3.  I^     Olei  chenopodii,  Bi     30.0 

Sig. — Eight  to  fifteen  drops  t.i.d.,  after  a  laxative. 

This  treatment  should  be  i;epeated  every  three  to  six 
months  in  children,  until  the  worms  are  expelled;  and  it  is 
more  effective  if  irrigations  are  given  every  evening  while  the 
remedy  is  being  taken,  so  that  the  benumbed  parasites  of  the 


328  DISEASES  OF  THE  DIGESTIVE  CANAL 

colon  may  be  washed  out  before  they  again  become  active. 
The  most  suitable  preparation  to  be  used  in  this  way  is  an 
infusion  of  three  or  four  garlic  leaves  in  a  cu})  of  water. 

'  In  cases  of  oxyuris,  it  is  useful  to  anoint  the  anus  every 
evening  with  gray  salve,  which  will  kill  the  worms  that  escape 
from  the  rectum  during  the  night.  The  tincture  of  absinthe 
is  also  effective  when  taken  in  doses  of  ^  to  1  teaspoonful  three 
times  daily. 

2.  Tapeworms. — It  is  often  verj^  difficult  to  bring  about 
the  expulsion  of  tapeworms,  especially  in  patients  who  vomit 
the  administered  vermifuge.  As  a  general  rule,  I  conduct  the 
treatment  as  follows: 

At  8:00  o'clock  in  the  morning,  the  patient  is  given  a  dry  roll;  at  12:00 
o'clock  a  plate  of  soup  and  a  small  amount  of  vegetables,  but  no  meat;  at 
4:00  o'clock,  a  cup  of  coffee;  at  7:00  o'clock,  some  herring,  or  an  Italian  or 
herring  salad;  at  10:00  o'clock  in  the  evening,  he  should  take  two  table- 
spoonfuls  of  castor  oil,  which  will  usually  oblige  him  to  go  to  the  toilet  during 
the  night.  The  next  morning  about  6:00  o'clock,  he  should  take  four  or  five 
capsules,  each  containing  1.0  [gr.  xv]  of  the  fresh  oleoresin  of  aspidium. 
At  6:30  o'clock,  a.m.,  the  patient  should  again  be  given  four  or  five  capsules; 
and  at  8:30  a.m.,  two  tablespoonfuls  of  castor  oil,  a  glass  of  mineral  water, 
or  a  tablespoonful  of  an  infusion  of  senna  every  half-hour. 

The  movements  of  the  bowels  resulting  from  the  above 
treatment  should  be  deposited  in  a  closed  vessel  and  thoroughly 
examined  for  the  head  of  the  tapeworm. 

If  the  physician  does  not  wish  to  conduct  the  examination 
personally,  he  may  instruct  the  patient  that  the  head  is  a 
nodular  thickening  on  the  tapering  end  of  the  worm  and  that 
it  shows  four  dark  points. 

If  only  segments  of  the  worm  are  passed,  or  if  only  one 
end  of  the  worm  protrudes  from  the  anus  after  the  second  dose 
of  castor  oil,  a  thorough  irrigation  with  two  or  three  litres  of 
lukewarm  water  should  be  given,  when  usually  the  head  of 
the  worm,  which  has  been  lying  benumbed  in  the  intestine, 
will  be  obtained. 

During  the  treatment,  the  patient  should  remain  in  bed. 

If  the  results  are  negative  after  one  or  two  ''cures"  have 
been  given,  the  patient  should  place  himself  under  the  imme- 


DISEASES  OF  THE  INTESTINE  329 

diate  observation  of  the  physician,  who  should  supervise  the 
irrigation  and  procedures  of  treatment  at  the  correct  time. 

The  expulsion  of  a  tapeworm  is  especially  difficult  in 
children.  The  extract  of  male  fern  should  not  be  administered 
simultaneously  with  oil,  as  the  latter  renders  the  constituents 
of  this  poison  soluble,  which  if  absorbed  might  cause  hepatitis 
and  intoxication. 

In  addition  to  the  above-mentioned  extract  of  male  fern, 
the  administration  of  which  should  always  be  tried  first,  the 
following  vermifuges  may  be  used: 

1.  I^     Extract!  filicis  maris  sether.,  gtt.  xlviii  to  Ix     .3.0-4.0 

Chloroformi,  gtt.  vi 
Olei  ricini, 

Mucilaginis  acaciae,  aa,  oi  30.0 

Aquse  destillatse,  q.  s.  ad  oviss  200.0 

M.  ft.  emulsio.      Sig. — Introduced  through  a  stomach-tube  early 
in  the  morning. 

2.  I^     Granati  corticis,  oi-oiss     30.0-50.0 

Mac.  per  hor.  xii  cum  200-300  aq.  dest.  deinde  coque  ad  remanentiam  150.0 
Sig. — Drink  the  above  or,  preferably,  introduce  it  through  a  stomach-tube,  early 

in  the  morning. 

Contraindications. — The  contraindications  against  the 
use  of  the  tapeworm  remedies  are  gastro-enteritis,  or  a  con- 
dition of  emaciation  and  weakness,  because  the  tapeworm 
treatment  is  extremely  exhausting  to  the  patient,  and  not  only 
aggravates  the  existing  catarrh  but  also  is  frequently  the  cause 
of  a  gastro-enteritis,  which  might  become  permanent. 

Since  the  life  of  the  tapeworm  is  about  six  or  seven  years,  it  is  always 
better  to  await  the  death  of  the  parasite  than  to  weaken  an  already  enfeebled 
patient  by  a  radical  cure.  I  have  several  times  observed  the  final  disap- 
pearance of  a  worm  in  cases  where  two  or  three  inefficient  treatments  had 
been  given  and  the  trouble  had  always  recurred. 

There  should  be  an  interval  of  three  or  four  months 
between  two  treatments  for  tapeworm,  to  allow  the  mucous 
membrane  of  the  intestine  to  return  to  its  normal  condition, — 
otherwise  the  tapeworm  would  be  the  lesser  evil. 


330  DISEASES  OF  THE  DIGESTIVE  CANAL 

Complications. — Complications  in  the  treatment  of  tape- 
worm are  intoxications.  Death  has  resulted  from  the  use  of 
male  fern,  but  usually  only  after  excessive  doses  of  15  to  20 
grams  or  more. 

Symptoms  of  intoxication  are  a  severe,  painful,  and  even 
bloody  diarrhcra;  enlargement  of  the  liver,  jaundice,  fever, 
coma,  albuminuria,  amaurosis,  and  collapse. 

The  treatment  consists  in  the  administration  of  stim- 
ulants. If  the  patient  survives  immediate  danger,  the  condition 
should  be  treated  as  any  other  toxic  gastro-enteritis  or  hepatitis. 

Poisoning  from  santonin  causes  vertigo,  cramps,  yellow 
vision,  etc. 

REMARKS 

Concerning  the  other  parasites  of  the  intestinal  canal,  we  cannot  go 
into  detail.  A  discussion  of  the  various  infusoria  is  of  no  practical  impor- 
tance, for  the  reason  that  a  patient  thus  infected  ahvays  suiters  from  intes- 
tinal inflammation  or  ulceration,  which  should  be  treated  as  such. 

Ankylostomiasis  should  also  be  treated  with  male  fern,  while  tricho- 
cephaliasis,  in  which  the  eggs  are  frequently  found  in  the  stools,  should  be 
treated  with  santonin.    The  remaining  parasites  are  curiosities  in  Germany. 

DISEASES   OF  THE   RECTUM 

Although  exactly  the  same  diseases  affect  the  rectum  as 
the  other  portions  of  the  intestinal  tract,  I  will,  for  practical 
purposes,  devote  a  special  chapter  to  their  consideration. 

Here  again  we  have  primary,  organic  diseases, — such  as 
catarrh,  inflammations,  ulcerations,  and  new  growths, — and 
secondary  organic  conditions, — such  as  stenoses,  dilatation, 
fistula?,  abscesses,  prolapsus  of  the  rectum;  and  finally  func- 
tional-nervous diseases  of  the  rectum, — such  as  relaxations, 
spasms,  crises,  etc. 

I  have  considered  only  the  individual  affections  that  are 
of  interest  to  the  internist.  Many  of  the  diseases  of  the  rectum 
must  be  left  to  the  treatment  of  the  surgeon. 

One  of  the  most  important  things  to  emphasize  in  this 
place  is,  that  the  physician  should  never  permit  himself  to 
neglect  making  a  digital  examination  of  the  rectum. 

For  an  accurate  examination,  a  rectoscope, — preferably 
that  of  Strauss, — is  essential. 


DISEASES  OF  THE  INTESTINE  331 

1.  Catarrh  and  Inflammation  of  the  Rectum 

Inflammation  of  the  rectum  is  found  in  widely  varying 
intensit}'',  from  the  simple  hypersecretion  of  mucus  to  the 
formation  of  erosions.  Very  mild  cases  may  run  a  clinical 
course  without  symptoms;  while  severe  cases  present  very 
striking  objective  and  subjective  symptoms,  which  may  even 
progress  to  ulceration. 

Etiology. — Acute  proctitis  is  usually  caused  by  gonor- 
rhoeal  infection  from  using  rectal  tubes,  etc.;  or  it  may  simply 
be  a  local  symptom  of  severe  gastro-enteritis. 

The  causes  of  chronic  proctitis  are:  Fecal  accumulations 
in  chronic  constipation,  especially  when  the  patient  has  hem- 
orrhoids; too  frequent  enemata  of  various  solutions;  and  the 
presence  of  parasites,  especially  oxyurides. 

Intense  catarrh,  i.e.,  that  which  is  associated  with  frequent 
tenesmus  and  the  passage  of  mucopurulent  faeces,  with  or  with- 
out blood,  is  the  symptom  of  a  general  catarrh  of  the  intestine. 
The  condition  is  likewise  a  symptom  of  other  severe  affections 
of  the  intestine, — such  as  ulcer,  carcinoma,  and  stenosis. 

Symptomatology. — In  acute  proctitis,  besides  diarrhoea  the 
patient  has  tenesmus,  with  passages  of  purulent,  bloody  mucus. 

The  mucosa  of  the  rectum  is  reddened  and  swollen. 

In  mild  cases  of  chronic  catarrh,  the  scybala  that  are 
passed  are  covered  with  opaque  or  yellowish-brown  clumps  of 
mucus  in  which  many  epithelia  are  found,  but  few  leucocytes. 

In  severe  cases  of  chronic  proctitis,  the  patient  is  obliged 
to  go  to  stool  from  six  to  ten  times  in  twenty-four  hours, 
usually,  however,  without  results,  except  the  passage  of  one 
or  two  tablespoonfuls  of  a  turbid  fluid  in  which  large  clumps 
of  white  corpuscles  and  isolated  red  cells  are  found. 

The  mucous  membrane  of  the  rectum,  which  is  normally 
■quite  smooth  and  of  a  rosy  color,  presents  itself  in  the  recto- 
scope  as  puffed,  wrinkled  and  cyanotic,  often  covered  with  small 
erosions  which  bleed  easily  if  stroked  lightly  with  the  apphcator. 

Chronic  eczema  of  the  anal  margin  is  frequently  observed 
in  proctitis. 


332  DISEASES  OF  THE  DIGESTIVE  CANAL 

Diagnosis. — The  diagnosis  of  catarrh  of  the  rectum  is 
made  from  the  tenesmus,  from  the  frequent  escape  of  muco- 
purulent secretion,  and  from  the  examination  of  the  rectum 
with  a  tubular  rectoscope,  such  as  that  of  Strauss  or  Herzstein. 

Differential  Diagnosis. — The  physician  should  always 
think  of  the  insidious  dovelopment  of  a  new  growth  when  the 
patient  suffers  from  chronic  or  subacute  proctitis.  A  recto- 
scopic  and  digital  examination  must  be  made  to  eliminate 
such  conditions  from  the  diagnosis. 

Treatment. — Acute  proctitis  responds  readily  to  rest  in 
bed,  a  non-irritating  diet,  prolonged  warm  sitz-baths,  hot 
compresses,  and  antispasmodic  remedies.  Sitz-baths  should 
be  taken  for  a  half-hour  three  times  daily,  of  a  temperature 
of  30°  R.  [100°  F.].  If  tenesmus  is  severe,  the  following 
suppositories  will  be  found  helpful: 

1.  I^     Extract!  opii,  gr.  i.  0.01 

Extracti  belladonnse  foliorum,  gr.  |     0.05 
Olei  theobromatis,  gr.  xxx  2.0 

Ft.  suppos.  i.     Sig. — To  be  introduced  t.i.d. 

The  application  of  leeches  to  the  anal  region  also  affords 
the  patient  considerable  relief.  Rosenheim  recommends  irriga- 
tion with  a  mucilaginous  solution  or  with  a  linseed  decoction 
to  which  10  drops  of  the  tincture  of  opium  have  been  added. 

The  following  should  be  given  in  gonorrhoeal  proctitis: 

Zinc  sulphate,  gr.  iii-v  to  oviss,  0.2-0.5  to  200; 

Silver  nitrate,  gr.  iss-ivss  to  oviss,      0.1-0.3  to  200; 
or  alum  or  tanin  solution,  0.5  to  2.0  per  cent. 

For  certain  cases,  where  all  the  above  treatment  has 
proved  ineffective,  Rosenberg  has  recently  employed  the 
following  powder,  sprayed  through  the  rectoscope: 

Tannic  acid,  oiv  15.0 

Magnesia  usta,  oiiiss         100.0 

(or  bismuth  subnitrate  or  xeroform.) 

In  erosions  or  ulcers  of  the  rectum  or  of  the  sigmoid  flex- 
ure, after  the  diseased  areas  have  been  cleansed  with  hydrogen 
peroxide  solution,  they  should  be  cauterized  with  |  to  1  per 


DISEASES  OF  THE  INTESTINE 


333 


cent,  solution  of  silver  nitrate,  after 
which  they  should  be  touched  lightly 
with  a  solution  of  sodium  chloride. 

Slight  cases  of  chronic  proctitis  do 
not  require  any  special  treatment;  they 
disappear  when  the  etiological  factor, 
such  as  habitual  constipation  or  intesti- 
nal parasites,  has  been  eliminated. 

Severe  cases  of  chronic  proctitis 
require  local  treatment.  It  is  best  to 
try,  at  first,  irrigations  with  chamomile 
tea  or  normal  saline  solution,  morning 
and  evening.  If  these  produce  no  suc- 
cessful results,  irrigations  should  be 
made  v/ith  at  least  200  to  250  cc.  of 
the  following  solutions : 

Tannin,  5  to  1000;  silver  nitrate, 
1  to  1000;   bismuth  emulsion,  8  to  250. 

In  very  stubborn  and  persistent 
cases,  silver  nitrate  1.0-5.0  [gr.  xv- 
Ixxv]  to  100  should  be  locally  applied. 

A  well-oiled  Nelaton  catheter  and 
the  ordinary  rubber  syringe  should  be 
used  for  irrigations  and  to  be  most 
effective,  the  fluid  should  be  retained  in 
the  intestine  for  a  few  moments. 

Irrigations  should  be  continued 
once  or  twice  daily  for  a  few  weeks. 
During  this  time,  the  patient  should  have 
as  complete  physical  rest  as  possible, 
and  a  mild  constipation-diet,  to  which  he 
should  occasionally  add  mild  laxatives, 
— such  as  rhubarb  or  licorice  powder, — 
if  the  diet  is  ineffectual  in  causing  spon- 
taneous evacuations  of  the  bowels. 


Fig.  44. — Rectal  irrigator  (Strauss).  The  irrigator  is  inserted  and 
the  rubber  balloon  is  introduced  past  the  sphincter  and  then  inflated, 
which  prevents  the  escape  of  the  irrigation  solution. 


334  DISEASES  OF  THE  DIGESTIVE  CANAL 

In  very  stubborn  cases,  Rosenheim  resorts  to  treatment 
with  salves,  applying  zinc  or  bismuth  ointment  with  the  Am- 
erican ointment-injector,  which  the  patient  can  use  himself. 

Franzensbad,  Elster,  and  other  chalybeate  watering-places 
are  indicated. 

2.  Ulceration  of  the  Rectum 

Ulcers  of  the  rectum  are  of  the  most  varying  intensity 
and  extent,  from  flat,  pea-sized  erosions  to  deep  ulcerations 
as  large  as  a  five-cent  piece. 


Fig.  45. 


^ 


Etiology. — Severe  irritation  of  the  rectum  may  lead  to 
erosion  and  ulceration,  as  ma}^  be  seen  in  the  previous  chapter. 
The  most  frequent  causes  of  ulceration  are  infections  from 
gonorrhoea,  syphilis,  tuberculosis,  dysentery,  typhoid  fever, 
pyaemia,  etc. 

Gonorrhoeal  infection  occurs  most  frequently  in  women 
through  taking  enemata  with  an  infected  syringe. 

The  causes  of  infection  in  tubercular  and  syphilitic  ulcer- 
ation are  less  clear,  although  in  tuberculosis  an  ulcer  frequently 
arises  from  the  breaking  through  of  a  peritoneal  abscess. 
Ulcers  of  the  rectum  rarely  result  from  intoxications. 

Symptomatology. — The  subjective  symptoms  consist  of 
tenesmus  and  severe  pains  in  the  rectum  which  radiate  to 
the  sacrum. 

Objective  signs  are  muco-blood}'  and  purulent  discharges, 
hemorrhages,  and  the  macroscopic  demonstration  of  ulcers 
through  the  rectoscope. 


DISEASES  OF  THE  INTESTINE  335 

Diagnosis. — Fissures,  erosions,  and  ulcers  situated  in  the 
anal  margin  may  be  easily  recognized;  while  to  discover  those 
located  higher  in  the  intestine,  a  rectoscope  is  required.  An 
accurate  diagnosis, — especially  a  differentiation  from  severe 
inflammation, — is  not  possible  without  direct  inspection  of 
the  mucous  membrane  of  the  rectum. 

Treatment. — The  treatment  of  catarrhal  ulceration,  which 
usually  consists  of  superficial  erosions,  has  been  given  in  the 
previous  chapter. 

Excoriation  and  ulceration  from  gonorr.hoeal  infections 
should  be  treated  with  warm  sitz-baths,  injections  of  alum, 
tannin,  silver  nitrate,  or  other  astringent  solutions,  and 
cauterization  with  zinc  chloride,  20  to  100,  applied  with  a 
cotton  applicator  through  the  rectoscope. 

3.  Fissures  and  Erosions  of  the  Anus 

Erosions  and  fissures  are  located  in  the  circumference  of 
the  anus.  The  fissures  present  flat  breaks  in  the  mucous 
membrane,  sometimes  about  the  size  of  a  bean,  with  swollen 
edges  and  purulent  bases. 

Etiology. — These  lesions  most  frequently  arise  from  one 
of  the  following  causes : 

Inflammation  of  hemorrhoidal  tumors;  rupture  of  the 
mucous  membrane  caused  by  straining  at  stool,  or  the  passage 
of  extremely  large-sized  stools;  or  the  above-described  gon- 
orrhoeal  proctitis. 

Symptomatology. — Erosions  usually  cause  nothing  more 
than  itching  and  burning  around  the  rectum;  while  the  fis- 
sures, in  spite  of  their  small  size,  very  frequently  produce 
extreme  pain  around  the  anus  and  its  region,  this  pain  often 
radiating  to  different  parts  of  the  pelvis.  Usually  after  def- 
ecation, spasm  of  the  sphincter  ani  occurs,  which  ma}^  persist 
for  hours;  so  that  patients,  from  fear  of  this  suffering,  delay 
going  to  stool  as  long  as  possible.  Small  amounts  of  blood 
and  pus  frequently  appear  in  the  stool. 

Diagnosis. — The  symptoms  are  so  characteristic, — espe- 
cially the  spasmodic  contraction  after  defecation, — that  they 


336  DISEASES  OF  THE  DIGESTIVE  CANAL 

immediately  suggest  the  necessity  of  examining  the  rectum. 
A  fissure  is  often  very  difficult  to  see,  because  it  is  painful  for 
the  patient  to  press  down  sufficiently  to  expose  the  fissured 
surface.  But  by  carefully  drawing  out  the  anal  folds,  when 
the  patient  is  in  the  knee-elbow  position,  the  fissures  may 
usually  be  brought  to  view.  They  often  lie  deeply  within  the 
folds  of  the  mucous  membrane. 

Treatment. — The  stools  should  be  kept  soft  by  the  use 
of  a  suitable  diet,  laxatives,  and  irrigations  of  oil.  Before 
defecation,  the  rectum  should  be  lubricated  with  oil  as  thor- 
oughly as  possible  with  the  finger. 

It  is  best  at  first  to  tr}^  two  medicaments, — silver  nitrate 
and  pure  ichthyol.  After  cocainizing  or  anaesthetizing  the 
patient,  the  fissure  should  be  thoroughly  cauterized  with 
caustic  potash,  after  which  the  patient  should  stay  in  a  recum- 
bent position  for  two  or  three  days,  during  which  time  con- 
stipation should  be  induced  by  the  administration  of  opium. 

Ichthyol  should  be  applied  twice  daily  to  the  fissure, 
using  a  match  or  an  applicator  wrapped  with  cotton.  A  great 
many  of  the  milder  cases  may  be  cured  in  a  few  weeks  by  the 
use  of  ichthyol  alone. 

Boas  treats  stubborn  cases  as  follows: 

After  a  thorough  evacuation  of  the  bowels  by  the  use  of 
castor  oil,  the  patient  should  he  in  bed  for  eight  days  and  be 
given  10  to  15  drops  of  the  tincture  of  opium  three  times 
daily.  The  diet  should  be  light,  such  as  will  furnish  as  httle 
intestinal  debris  as  possible.  After  the  eight  days,  the  patient 
should  be  given  a  large  dose  of  castor  oil. 

Rosenbach  recommends  that  the  patient  himself  dilate 
the  rectum  with  the  little  finger,  when  in  the  squatting  position. 
This  treatment  should  last  about  one-quarter  of  an  hour,  and 
should  be  performed  night  and  morning.  Chronic  cases  that  re- 
fuse operation  should  especially  make  use  of  this  dilatation- 
treatment,  because  the  spasmodic  contraction  of  the  sphincter 
is  thereby  relieved. 

Finally  the  dilatation  and  incision  of  the  sphincter  comes 
into  question.     Under  narcotics,  the  rectum  should  be  thor- 


DISEASES  OF  THE  INTESTINE  337 

oughly  stretched  by  means  of  the  two  thumbs  introduced 
into  the  rectum.  Incision  should  then  be  made,  after  which 
the  fissure  will  generally  be  completely  healed  in  from  one  to 
two  weeks. 

Erosions  and  anal  eczema  are  best  treated  with  dusting 
powders,  such  as  orthoform,  xeroform,  or  with  an  ointment 
composed  as  follows: 

Orthoform, 

Xeroform,  aa,  gr.  xv        1.0 

Zinc  oxide,  5 iiss  10.0 

Vaselinol,  5  iiss  10.0 
(or  Thigenol,  gr.  xlv      3.0) 

Lanolin,  oiv  15.0 

After  cleansing  the  affected  areas  at  night,  a  bit  of  oint- 
ment the  size  of  a  bean  should  be  thoroughly  rubbed  in. 

4.  Neoplasms  of  the  Rectum 

Of  the  benign  tumors  of  the  rectum,  the  polyps  have 
especial  clinical  significance,  from  the  fact  that  they  may  lead 
to  profuse  hemorrhage. 

Rectal  polyps  are  most  frequently  found  in  women  after 
gonorrhoeal  infection. 

Very  frequently  the  bleeding  which  results  from  these 
polyps  is  for  a  long  time  considered  to  be  of  hemorrhoidal 
origin,  until  digital  examination  renders  the  diagnosis  clear. 

The  treatment  is  surgical. 

The  other  benign  tumors, — such  as  cysts,  fibromata, 
etc., — rarely  occur;  the  only  ones  deserving  especial  con- 
sideration being  the  angiomata,  i.e.,  hemorrhoids. 

Hemorrhoids 

Hemorrhoids  are  caused  by  the  dilatation  or  the  new 
formation  of  blood-vessels,  brought  about  by  sedentary 
habits,  obstruction  of  the  portal  circulation,  or  chronic  con- 
stipation (see  Etiology  of  Chronic  Constipation). 

Symptoms. — Slight  cases  very  frequently  run  a  clinical 
course  accompanied  by  no  pain,  and  perhaps  by  only  a  little 
itching;  the  patient  notices  only  that  sometimes  the  toilet- 
paper  is  colored  bright  red  with  blood. 

22 


338  DISEASES  OF  THE  DIGESTIVE  CANAL 

The  symptoms  of  the  disease  begin  acutely  when  the 
hemorrhoidal  nodules  become  inflamed,  before  which  time 
the  patients  rarely  consult  a  physician. 

The  pain  is  of  a  burning,  boring,  pricking,  and  occasionally 
cramp-like  character, — especially  after  stools, — and  is  usually 
increased  by  the  sitting  posture. 

The  anal  mucous  membrane  is  swollen  and  of  a  bluish-red 
color.  By  pressing  clown,  tense  nodules  ranging  in  size  from 
that  of  a  bean  to  that  of  a  hazel-nut  are  caused  to  protrude 
from  the  anal  margin;  while  the  finger  will  usually  palpate 
similar  hemorrhoids  situated  within  the  bowel. 

Profuse  hemorrhage  often  occurs. 

If  there  are  breaks  in  the  continuity  of  the  mucous  mem- 
brane, spasm  of  the  rectum  is  a  prominent  symptom. 

Diagnosis. — In  the  diagnosis  three  tasks  should  be  fulfilled : 

1.  To  demonstrate  the  source  of  the  bleeding;    whether 

it  is  actually  caused  by  hemorrhoids  or  by  a  polyp, 
carcinoma,  or  ulceration. 

2.  Whether  isolated  hemorrhoids  exist;    or  whether  the 

entire  mucosa,  both  internal  and  external,  is  diseased. 

3.  Whether  the  hemorrhoids  are  inflamed  or  not. 

It  is  scarcely  possible  for  confusion  to  occur  in  the  diag- 
nosis if  accurate  inspection  and  careful  digital  examination 
of  the  rectum  are  made. 

Therapy. — There  are  three  indications  for  treatment: 

1.  To  reduce  the  inflammation  of  the  hemorrhoids. 

2.  To  bring  about  a  contraction  of  the  hemorrhoids. 

3.  To  prevent  their  recurrence. 

I  generally  institute  the  following  measures,  and  have 
thus  obtained  permanently  good  results  in  a  large  number  of 
cases: 

1.  For  three  to  six  days,  I  have  the  patient  apply  cold 
compresses  to  the  rectum  when  in  the  dorsal  position  with 
hips  elevated.  In  mild  cases,  this  should  be  done  three  times 
daily  for  one-half  hour, — early  in  the  morning,  at  mid-day, 


DISEASES  OF  THE  INTESTINE  339 

and  in  the  evening;  while  in  severe  cases,  the  compresses 
should  be  worn  the  entire  day.  Lead  and  opium  water,  or 
aluminum  acetate,  one  tablespoonful  to  a  cup  of  water,  may 
be  added  to  these  compresses.  During  the  treatment,  the 
patient  should  expose  the  hemorrhoids  as  much  as  possible 
by  downward  pressure. 

During  this  period  the  bowels  should  be  regulated  by 
low  enemata. 

After  three  or  four  days  of  this  treatment,  the  hemorrhoids 
are  no  longer  swollen  and  painful. 

To  control  the  bleeding  from  external  hemorrhoids,  tannin 
1  to  2  per  cent,  and  alum  1  to  3  per  cent.,  should  be  applied; 
while  for  internal  hemorrhoids,  the  same  preparation  should  be 
injected  with  a  rectal  syringe.  Prolapsed  hemorrhoids  should, 
according  to  Rosenheim,  be  touched  with  the  following: 

I^.     Potassii  iodidi,  gr.  xxx         2.0 
lodi,  gr.  iii  0.2 

Glycerini,  oxii  40.0 

Erosions  should  be  painted  with  zinc  amylum  paste. 

2.  To  reduce  the  size  of  the  hemorrhoids,  I  have  found 
extract  of  hamamelis  the  most  suitable.  I  usually  prescribe 
twelve  suppositories,  each  containing  the  following: 

Extr.  of  hamamelis  virg.,  gr.  ivss      0.3 

Orthoform  (if  painful),  gr.  ivss  0.3 

Cocoa  butter,  gr.  xxx  2.0 

M.     Sig. — Suppository,  introduced  night  and  morning. 

For  three  or  four  weeks,  I  prescribe  ^  teaspoonful  of  the 
fluiclextract  of  hamamelis,  to  be  taken  after  meals. 

For  frequently  recurring  or  for  chronic  hemorrhages  from 
internal  hemorrhoids,  cold  irrigations  with  Arzberger's  "re- 
frigerator," as  employed  in  diseases  of  the  prostate,  are  very 
useful. 

The  diet  throughout  the  treatment  should  be  the  coarse 
constipation-diet  if  atonic  constipation  is  present;  or  the 
mild  constipation-diet,  if  there  is  spastic  constipation.  If 
rectal  spasms  are  troublesome,  oil  enemata  should  be  given 
every  other  night. 


340  DISEASES  OF  THE  DIGESTIVE  CANAL 

.  3.  To  prevent  recurrence,  the  patient  should  take  a  cold 
sitz-bath  every  day,  lasting  ten  minutes,  and  use  the  Hautel 
pessary  with  a  central  perforation  for  the  escape  of  gases. 
The  hamamelis  suppository  treatment  should  be  repeated 
every  three  months,  with  the  diet  adapted  to  the  nature  of 
the  constipation;  when  it  is  atonic,  I  occasionally  prescribe 
compound  licorice  powder,  rhubarb  tablets,  laxative  mineral 
water,  or  Glauber's  salt;  when  the  constipation  is  of  the 
spastic  variety, — oil  enemata,  and  the  mineral-water  treat- 
ment at  Kissingen,  Marienbad,  Carlsbad,  Franzensbad,  Elster, 
Tarasp,  Homburg,  etc.,  or  the  grape-cures  afforded  at  the 
health-resorts  along  the  Rhine  near  Lake  Geneva, — at  Vevey, 
Montreux,  Territet,  etc. 

The  injection  of  carbolic  acid  in  the  treatment  of  hem- 
orrhoids should  be  discarded,  because  of  the  clanger  of 
embolism. 

Boas  has  recently  recommended  the  use  of  a  10  per  cent, 
solution  of  calcium  chloride,  10  c.c.  of  which  he  injects  once 
or  twice  daily. 

For  the  relief  of  painful,  itching  and  bleeding  hemorrhoids 
the  following  prescriptions  are  recommended: 

1.  I^     Chrysarobini,  gr.  IJ  0.08 

lodoformi,  gr.  J  0.02 

Extract!  belladonnse  foliorum,  gr.  J       0.01 
Olei  theobromatis,  gr.  xxx  2.0 

M.  ft.  suppos.  i,  No.  XV.     Sig. — Use  one  or  two 
suppositories  daily. 

2.  ^     Clirysarobini,  gr.  iss  0.1 

Acidi  tannici,  gr.  iss  0.1 

lodoformi,  gr.  iii  0.2 

Extracti  belladonnse  foliorum,  gr.  J       0.02 
Olei  theobromatis,  gr.  xxx  2.0 

M.  ft.  suppos.   i,  No.   xii.     Sig. — Use  two  or 
three  daily. 

3.  1^     Chrysarobini,  gr.  xii  0.8 

lodoformi,  gr.  ivss  0.3 

Extracti  belladonnse  foliorum,  gr.  viiiss     0.6 

Vaselini,  oiv  15.0 

M.  ft.  unguentum.     Sig. — Apply  several  times  daily. 


DISEASES  OF  THE  INTESTINE  341 

A  large  number  of  old,  persistent  cases  have  improved  by 
this  treatment  in  my  clinic  to  such  a  degree  that  all  the  synij)- 
toms  disappeared.  Plowever,  there  are  always  cases  that  can 
be  cured  only  by  operation, — especially  internal  hemorrhoids. 

Prognosis. — The  prognosis  of  hemorrhoidal  affections  is 
good.  The  sufTerer  generally  becomes  weakened  only  by  loss 
of  blood  or  by  severe  continuous  pain.  Otherwise,  the  general 
condition  of  the  patient  rarely  suffers,  although  in  some  cases 
the  hemorrhoids  become  so  severe  and  the  constitutional  re- 
action is  so  marked  that  the  patient  has  a  cachectic  appearance. 

Complications. — The  most  important  comphcations  are 
inflammation,  fissures,  erosions,  rectal  fistulse,  or  abscess, 
occasionally  thrombosis  and  embolism,  and  finally  prolapsus  of 
the  mucous  membrane  of  the  rectum,  with  hemorrhoidal 
tumors. 

Sometimes  hemorrhoids  are  the  result  of  constipation,  and 
sometimes  its  cause. 

When  the  disease  has  existed  for  years,  the  patient 
frequently  becomes  hypochondriacal  and  neurasthenical. 

CLINICAL    CASE 

Case  1. — Mrs.  S.,  a  widow  36  years  old,  had  suffered  from  constipation 
for  ten  years.  Purgatives  and  enemata  had  been  effective  only  when  taken 
in  large  amounts.  For  about  nine  months,  the  patient  had  had  severe  rectal 
pains  and  hemorrhages.  Every  four  or  five  weeks,  she  lost  three  or  four 
teaspoonfuls  of  blood  daily.  Examination  showed  the  presence  of  external 
and  internal  inflamed  hemorrhoids. 

Treatment. — The  patient  was  given  rest  in  bed  for  one  week,  with  the 
application  of  lead  and  opium  water  compresses;  every  second  day  oil  was 
introduced  through  a  Nelaton  catheter;  hamamelis  suppositories  were  used 
during  the  second  week  of  treatment;  the  third  and  fourth  weeks,  a  teaspoon- 
ful  of  the  fluidextract  of  hamamelis  was  given  three  times  daily.  A  mild 
constipation-diet  and  oil  enemata  were  continued  for  three  months,  after 
which  the  patient  was  completely  cured. 

Malignant  Neoplasms  of  the  Rectum 

From  the  practical  standpoint,  only  carcinomata  of  the 
rectum  need  be  considered,  for  the  reason  that  other  neoplasms 
of  a  mahgnant  nature  are  very  exceptional. 


342  DISEASES  OF  THE  DIGESTIVE  CANAL 

Cancer  of  the  rectum  most  commonly  attacks  persons 
whose  previous  tligestion.has  been  almost  faultless.  The  dis- 
ease begins  insicliousl}',  the  patient  generally  coming  to  the 
physician  too  late  for  operation,  The  general  health  of  the 
patient  may  be  undisturbed,  the  appetite  remaining  excellent. 

Symptomatology. — The  subjective  symptoms  are  ag- 
gravated tenesmus,  drawing,  boring  pains  in  the  rectum  and 
left  side  of  the  abdomen,  and  painful  distention.  When  going 
to  stool,  instead  of  fecal  matter,  only  mucus, — or  sometimes 
blood, — will  appear  after  hard  straining;  the  patient  fre(|uently 
believing  he  has  hemorrhoids. 

Objectively,  a  malignant  neoplasm  is  revealed  by  digital 
examination  and  the  use  of  the  rectoscope. 

It  is  generally  crater-shaped  in  advanced  cases,  and  of 
the  form  of  a  ring.  It  may  involve  any  part  of  the  rectal 
mucosa..  The  cancerous  growth  is  usually  found  to  be  more 
extensive  than  appears  on  palpation.  The  diagnosis  is  very 
difficult  when  the  new  growth  is  located  high  up  in  the  bowels 
between  the  rectum  and  the  sigmoid  flexure. 

The  most  important  part  of  the  physical  examination, 
even  in  slightly  suspicious  cases,  is  to  make  a  digital  explor- 
ation of  the  rectum,  with  the  patient  in  the  knee-elbow  position; 
and  when  necessary  to  resort  to  the  rectoscope.  If  the  attend- 
ing physician  is  in  doubt  as  to  the  nature  of  a  lesion,  he 
should  always  consult  with  a  specialist  in  rectal  diseases  as 
early  as  possible. 

It  is  very  suggestive  of  cancer  of  the  rectum  to  find  a 
bloody,  purulent  mucus-discharge  of  a  dirty  brown  color  and 
of  the  consistency  of  cream. 

Cachexia  does  not  occur  until  the  last  stages  of  the  disease. 

Sometimes  colonic  "stiffenings"  are  observed  in  the 
region  of  the  sigmoid  flexure,  as  in  obstruction  of  the  bowels 
from  any  other  cause. 

Diagnosis. — The  diagnosis  of  cancer  of  the  rectum  can  be 
made  only  by  the  actual  inspection  and  palpation  of  the 
mahgnant  ncoplasni,  because  the  other  symptoms  are  found 
in  a  number  of  other  affections  of  the  rectum. 


DISEASES  OF  THE  INTESTINE  343 

Prognosis.  —  The  prognosis  is,  quod  vitam,  naturally 
absolutely  bad;  but  in  regard  to  prolonging  life,  it  is  not  so 
unfavorable  as  one  might  assume,  even  when  operative  treat- 
ment is  refused.  I  have  seen  quite  a  number  of  patients  that 
were  able  to  attend  to  their  business  and  felt  relatively  well, 
had  a  good  appetite,  and  only  occasionally  needed  to  resort 
to  the  use  of  a  purgative,  for  a  period  of  one  to  one  and  one- 
half  years  after  a  positive  diagnosis  of  cancer  of  the  rectum 
had  been  made. 

Treatment. — A  carcinoma  of  the  anterior  wall  of  the 
rectum,  which  is  in  close  intimacy  with  the  prostate  gland  and 
the  bladder,  should  not,  as  a  rule,  be  operated,  especially  if 
the  malignant  neoplasm  is  adherent  and  is  already  as  large  as 
a  dollar.  It  is  more  conservative  to  produce  an  artificial  anus 
at  a  later  period  in  the  disease, — which  is  more  favorable  for 
both  the  comfort  and  the  life  of  the  patient  than  a  premature 
radical  operation,  the  outcome  of  which  is  always  uncertain. 

Small  carcinomata  of  the  entire  rectum  and  cancers  of 
larger  size,  when  not  adherent  and  located  on  the  lateral  or 
posterior  wall  of  the  rectum,  should  be  immediately  referred 
to  a  surgeon  for  operation. 

In  addition,  it  should  be  said  that  in  every  case  the  physi- 
cian should,  early  in  the  disease,  consult  a  surgeon  to  decide 
whether  or  not  an  operation  is  indicated. 

Extensive  carcinomata  situated  in  the  anterior  wall  of 
the  rectum  should  be  treated  symptomatically,  with  the 
possible  creation  of  an  artificial  anus,  if  indicated,  later 
in  the  disease. 

The  internal  treatment  is  the  same  as  for  Stenosis  of  the 
Intestine,  to  which  chapter  the  reader  is  referred. 

I  generally  prescribe  a  diet  as  non-irritating  as  possible, 
and  rich  in  fruit  and  fats.  Vegetables  should  be  used  only  in 
purees.  There  should  be  plenty  of  fruit,  besides  butter, 
cream,  tender  meats,  eggs,  white  wine,  and  lemonade.  Lax- 
atives should  be  given  every  second  evening, — either  castor 
oil  or  salts  with  rhubarb;  besides  oil  enemata,  each  containing 
^  litre,  twice  a  week. 


344  DISEASES  OF  THE  DIGESTIVE  CANAL 

If  the  affection  is  painful  and  tenesmus  marked,  one  to 
three  suppositories, — each  containing  0.04  to  O.OO  [|  to  1  gr.] 
of  the  extract  of  belladonna, — should  be  given  one  to  three 
times  daily. 

Complications. — The  most  important  complication  of 
carcinoma  of  the  rectum  is  the  formation  of  the  rectovaginal 
and  rectovesicular  fistuhr,  the  treatment  of  which  is  surgical. 

5.  Benign  Stenoses  of  the  Rectum 

A  constriction  of  the  lumen  of  the  rectum  occasionally 
results  from  external  compression,  as  by  retroflexion  of  the 
uterus,  pelvic  tumors,  or  from  the  accumulation  of  an  exudate. 
The  most  common  stenoses  of  the  rectum  result  from  cicatricial 
formation  following  ulceration, — especially  of  a  venereal  nature. 

S3'philitic  strictures  of  the  rectum  are  most  frequent  in 
women,  and  are  a  very  severe  affection.  They  develop  insid- 
iously and  may  lead  to  total  atresia  of  the  rectum,  by  the 
formation  of  a  diaphragm-like,  radiating  scar  just  above  the 
anal  opening. 

Symptomatology. — The  symptoms  of  benign  stenosis  of 
the  rectum  consist  of  pressure,  tenesmus,  mucous  diarrhoea, 
hemorrhage,  and  borborygmus. 

Objectively,  the  stenosis  itself  may  easily  be  palpated. 
The  scar-formation  is  usually  ring-shaped,  resembling  a  funnel 
whose  end  presents  a  round  opening,  the  lumen  of  which 
varies  in  thickness  from  the  diameter  of  a  knitting-needle  to 
that  of  the  finger.  The  mucosa  above  the  strictured  area  is 
reddened  and  inflamed.  The  stool  is,  of  course,  delayed  in 
expulsion;  and  in  advanced  cases,  the  stricture  may  develop 
into  complete  ileus. 

Diagnosis. — The  diagnosis  is  easily  made  by  palpation. 

Treatment. — When  a  benign  stenosis  is  of  recent  forma- 
tion, and  the  little  finger  can  still  be  introduced,  the  stricture 
should  be  dilated  with  the  well-known  Enghsh  bougie,  which 
has  a  receding  conical  end.  The  dilatation  should  be  made 
every  day  for  several  weeks.  There  is  always  a  tendency 
toward  relapse  when  the  dilatations  are  discontinued. 


DISEASES  OF  THE  INTESTINE  f345 

As  an  additional  treatment,  a  tablespoonful  of  a  6:200 
solution  of  iodide  of  potassium  should  be  given  three  times 
daily,  if  the  scars  are  recent  and  still  have  some  elasticity. 

Injections  of  a  ten  per  cent,  solution  of  thiosinamin 
(see  page  289)  into  the  tissues  around  the  anus  may  be  tried 
if  other  therapy  seems  hopeless. 

For  the  relief  of  pain,  suppositories  of  cocaine  and  bella- 
donna should  be  given;  and  as  laxatives,  castor  oil  or  saline 
mineral-waters  should  be  used  in  connection  with  oil  enemata 
two  or  three  times  a  week. 

Mild  cases  respond  quite  favorably  to  this  treatment; 
but  in  severe  cases,  the  patient  has  no  choice  but  to  submit  to 
either  the  extirpation  of  the  stenotic  area,  or  the  creation  of 
an  artificial  anus. 

6.  Other  Organic  Diseases  of  the  Rectum 

In  addition  to  those  already  discussed,  there  are  many 
diseases  of  the  rectum, — such  as  abscess-formation,  fistulse, 
prolapsus,  and  congenital  malformation, — -the  treatment  of 
which  belongs  so  naturally  to  the  domain  of  the  surgeon 
that  their  discussion  may  reasonably  be  omitted  in  a  work  on 
internal  medicine. 

7.  Nervous  Diseases  of  the  Rectum 

The  rectal  symptoms  that  sometimes  occur  in  the  course 
of  locomotor  ataxia  need  be  only  briefly  mentioned, — the 
most  important  being  incontinence  of  the  rectum  and  the  so- 
called  rectal  crisis,  which  is  characterized  by  periodically 
occurring  tenesmus,  unassociated  with  anatomical  lesions  of 
the  rectum. 

Rectal  incontinence  should  be  treated  with  cold  sitz- 
baths  and  endofaradization. 

As  accompanying  phenomena  in  diseases  of  the  entire 
intestinal  canal,  relaxation  and  spasmodic  contraction  of  the 
rectum  occur,  which  may  lead  to  functional  dilatation  or 
stenosis. 

The  reflex  irritability  of  the  rectum  in  hysterical  patients 
is  sometimes  so  pronounced  that  the  anal  sphincter  strongly 


346  DISEASES  OF  THE  DIGESTIVE  CANAL 

contracts  upon  the  palpating  finger.  Such  cases  should  be 
treated  with  irrigations  of  warm  oil  or  chamomile  tea,  and 
with  belladonna  suppositories.  Relaxation  of  the  rectal 
sphincter  should  be  treated  with  prolonged  cold  enemata,  of 
100  to  150  c.c.  of  water,  cold  sitz-baths,  carbonic-acid  full- 
baths,  rectal  douches,  etc. 

Sensory  neuroses  of  the  rectum   are  so   very  rare  that 
their  discussion  may  be  omitted. 


APPENDIX 


TABLE  TO  ASSIST  IN  THE  DIAGNOSIS  WITHOUT  THE  USE  OF  THE  TEST-BREAKFAST. 


General  Findings. 

Pain. 

Pressure. 

Vomiting. 

Stool. 

Habitus. 

Gastritis 

In  the  beginning, 
good,  especially 
in  acid  gastritis; 
later,  debility 
with  variable  ap- 
petite. 

Only  in  gas- 
tritis asso- 
ciated with 
stenosis  of 
the  pylorus. 

Aftersolids 

Unusual, 

except 

after  errors 

in  diet. 

Irregular, 

with 
frequent 
diarrhosa. 

Normal. 

Ulcer     

Appetite  very 
good,  except 
during  the  period 
of  pain.    Gen- 
eral state  of 
health  may  be 
good. 

Violent  yk  to 

41ioursafter 

eating. 

None. 

After  im- 
proper diet. 

Sluggish. 

Normal. 

Dilatation 

Appetite  good, 
except  in  dilata- 
tion due  to 
cancer.   General 
health  good 
except  ditring 
acute  attaclis. 

Of  gnawing 
character, 

which  is 
relieved  by 

vomiting. 

Constant. 

Copious,  5 
to  6  hours 
after  eat- 
ing. 

Sluggish. 

Normal. 

Carcinoma, 
without  ste- 
nosis. 

Poor,  aversion 
toward  meats. 

None. 

Aftersolids 

None. 

Sluggish. 

Normal. 

Atony 

Poor. 

None. 

After  all 

kinds  of 

food. 

None. 

Sluggish. 

Enterop- 

totic. 

Nervous    stom- 
ach affections 

Poor  or  variable. 

None. 

Most  of  the 
time. 

Often  im- 
mediately 
after  eat- 
ing. 

Sluggish. 

Enterop- 
totic. 

Enteritis 

Poor. 

None. 

Constant 
in  the 
entire 

abdomen. 

None. 

Soft,  spongy 
consist- 
ency. 

Either  nor- 
mal or 
enterop- 
totic. 

Poor. 

Colicky. 

Tension 
across  the 
abdomen. 

Unusual. 

Pulpy,  thin 
or  mucous. 

Either  nor- 
mal or 
enterop- 
totic. 

Atonic   consti- 
pation. 

Fairly  good. 

None. 

None. 

None. 

Hard  and 

large, 

resembling 

sausage. 

Usually  en- 
teroptotic. 

Spastic  consti- 
pation. 

Poor. 

Colicky. 

Distention 
and  pres- 
sure. 

Unusual. 

Surrounded 
by  mucus. 

Usually  en- 
teroptotic. 

347 


348  APPENDIX 

Outline  of  Dietetic  Treatment  of  Diseases 

of  the  Stomach  and  Intestine 

and  of  Metabolism 

Although  the  dietary  has  ah'eady  been  considered  in  the 
individual  chapters,  the  subject  will  once  more  be  briefly 
outlined. 

In  general,  the  following  ten  Diet-Forms  are  sufficient 
for  the  treatment  of  the  diseases  of  the  digestive  tract.  If 
there  is  a  complication,  rather  than  a  single  affection,  the 
physician  should  combine  the  diets;  as  an  example,  he  will 
sometimes  find  it  necessary  to  combine  a  constipation-diet 
with  one  suitable  for  gastritis,  or  a  forced-feeding  diet  with 
one  suitable  for  constipation,  etc. 

Ever}'  patient  should  be  given  a  diet-list  showing  the 
exact  time,  quality  and  quantity  of  his  meals;  the  time  for 
baths,  walking,  gymnastic  exercises,  massage  and  enemata; 
the  hour  of  rising  in  the  morning  and  of  going  to  bed  at  night, 
the  periods  of  rest  during  the  day,  and  the  hours  for  taking 
medicine  or  mineral-waters. 

The  arrangement  of  the  list  should  always  be  compatible 
with  the  occupation  of  the  patient  and  the  time  he  has  at  his 
disposal;  working  people  must  naturall}'  have  their  meals  at 
certain  hours,  while  those  who  have  no  occupation  can  be  at 
home  any  time. 

The  choice  of  foods  also  depends  a  great  deal  upon  the 
financial  circumstances  of  the  patient.  The  physician  must 
never,  therefore,  prescribe  foods  which  the  patient  is  unable 
to  buy, — otherwise  his  directions  will  not  be  followed. 

I.  Stenosis=Diet 

Indications. — In  benign  and  malignant  stenoses  of  the 
cardia,  pylorus  and  duodenum.     [CEsophagus.] 

Principle. — The  diet  must  be  of  fluid  consistency  and 
rich  in  fats  and  albumins.  In  stenosis  of  medium  degree,  the 
diet  may  be  semi-sohd.     In  benign  stenosis  of  the  pylorus, 


12: 

:00 

Noon 

3: 

00 

P.M. 

5: 

30 

P.M. 

8: 

00 

P.M. 

DIETETIC  TREATMENT  349 

where  hyperpepsia  exists,  tender  meats  may  be  allowed, — 
which  are  contraindicated  in  malignant  stenosis  associated 
with  achylia: 

7:00  A.M.  A  wineglassful  or  1  to  2  tablespoonfuls  of  olive  or  almond 
oil.  (If  there  is  a  repugnance  toward  these,  the  patient 
may  be  given  milk  of  almonds  or  butter.)  When  stag- 
nation is  present,  these  should  be  taken  immediately 
after  lavage. 
8:00  A.M.  One  cup,  or  200  to  250  c.c,  of  coffee,  tea  or  cocoa  with 
milk  or  cream. 
10:00  A.M.  Bouillon  with  1  or  2  yolks  of  eggs,  or  a  cereal  soup  rich  in 
butter. 

Broth  thickened  with  a  finely-ground  cereal,  butter  and  the 
yolks  of  eggs. 

Same  as  8:  00  a.m. 

Same  as  10:  00  a.m. 

Same  as  12:00  Noon,  with  perhaps  the  addition  of  sana- 
togen,  etc. 

As  refreshments, — lemonade,  wine  with  the  yolks  of  eggs, 
egg-cognac,  fruit-ice,  especially  vanilla  ice,  puro,  meat-jellies, 
calves'-foot  jelly,  buttermilk,  and  raw  eggs, — as  desired. 

In  stenosis  of  moderate  degree,  in  addition  to  the  above, 
the  following  are  allowed: 

Finely-prepared  purees  of  potato,  spinach,  carrots  and 
peas,  hght  puddings,  scraped  ham,  chopped  chicken,  anchovy, 
butter,  etc. 

2.  Gastritis=Diet 

Indications. — Hyperacid  gastritis,  subacid  gastritis,  anacid 
gastritis,  and  carcinomata  located  extra-ostially. 

Principle. — Such  a  diet  should  be  non-irritating,  of  semi- 
solid consistency,  and  arranged  according  to  the  state  of 
nutrition  of  the  patient  and  the  degree  of  constipation  present. 
Obese  persons  should  be  given  but  httle  butter;  emaciated 
persons,  a  great  deal.  Constipated  persons  should  be  given 
much  fruit  and  vegetables;  while  patients  with  diarrhoea 
should,  on  the  contrary,  be  given  constipating  articles 
of  food. 


350  APPENDIX 

7:00  a.m.     Mineral  water:   In  hyperacid  gastritis,  Carlsbad  or 
Vichy;    and  Homburg,  Kissingen,  or  Wiesbaden 
waters  in  subacid  or  anacid  gastritis. 
7:30  to    8:00  a.m.      Tea  with  milk  or  cream,  white  bread  and  butter; 
or  if  diarrhoea  is  present,  cocoa  or  chocolate  with 
bread  or  toast. 
10:00  to  11:00  a.m.      Cereal  soup  or  broth,  white  bread,  butter,  one  egg 
cooked  two  minutes,  and  scraped  ham. 
12:30  P.M.      Mineral  water. 
1:00  P.M.      Dinner:     Soup.      Puree   of    peas,    carrots,   spinach, 
asparagus    or    cauliflower,     cooked     in     butter; 
noodles,  macaroni,  or  rice  cooked  in  soup.    The 
tender  white  meat  of  chicken;    pigeon,  veal  or 
fish, — such  as  pike  or  perch;   sweet  fruit  purees, 
served  warm;  and  rice  or  sago  pudding. 
4 :  00  to    5 :  00  p.m.      Same  as  at  7 :  00  or  8 :  00  a.m. 

6:  30  P.M.      Mineral  water. 
7:00  to    8:00  p.m.      Gruel  or  cocoa  cooked  in  milk;  white  bread,  butter 
with  a  white  meat  or  two  soft  eggs. 

Strictly  Forbidden 

Cabbage,  legumes,  smoked  meats  of  all  kinds,  goose, 
duck,  animal  fats,  salmon,  acids,  pastries,  and  cold  drinks. 

Condiments  are  forbidden  in  hyperacidity,  but  indicated 
in  conditions  associated  with  subacidity. 

3.  Ulcer=Diet 

Indications. — Ulcers  and  erosions. 

Principle. — A  non-irritating  diet  which  will  leave  the 
stomach  quickly  and  excite  the  secretions  as  httle  as  possible. 

There  are  four  forms,  each  of  which  should  be  continued 
from  eight  to  ten  days:  (1)  fluid;  (2)  semi-hquid;  (3)  soft, 
orsemi-soHd;    (4)  non-irritating  soHds. 

The  subject  is  discussed  in  detail  in  the  chapter  on  Ulcer 
of  the  Stomach. 

Carcinoma,  dilatation,  and  hyperchlorhydria  need  no 
special  dietary. 

A  stenosis-diet  is  indicated  for  ostial  carcinomata;  a 
gastritis-diet,  for  extra-ostial  carcinomata. 

Dilatation  should  always  be  treated  at  first  with  the 
stenosis-diet. 


DIETETIC  TREATMENT  351 

In  hyperchlorhydria  (see  below),  a  diet  suitable  to  the 
primary  disease  is  indicated;  for  instance,  an  acid-gastritis 
diet,  an  ulcer-diet,  a  constipation-diet,  or  a  forced-feeding  diet. 

4.  Diarrhoea=Diet 

Indications. — Intestinal  catarrh  with  diarrhoea,  or  a 
strong  tendency  toward  diarrhoea. 

Principle. — A  diet  which  is  non-irritating,  astringent, 
free  from  food-debris  and  easily  absorbed. 

The  diet-hst  is  as  follows: 

7:  00  A.M.      Mineral  water;  hot,  and  taken  in  small  doses  of  75  to 

150  c.c.     The  choice  of  the  water  depends  upon 

the  state  of  the  gastric  secretions.     (See  previous 

chapter.) 
7:30  A.M.      Eiehel  cocoa  (2  teaspoonfuls  to  a  cup)  in  water,  and 

toasted  white  bread  and  butter. 
10:  00  A.M.      A  cereal  soup  with  butter,  toast  with  butter,  eggs  and 

scraped  ham. 
1:  00  P.M.      Broth  with  grits,  noodles,  macaroni,  and  white  meat; 

in  mild  cases,  vegetable  purees,  and  one  glass  of 

blueberry  wine. 
4:00  p.m.      Same  as  7:  30  a.m. 
6:  00  P.M.     Mineral  water. 
7 :  00  to    8 :  00  p.m.      Tea  with  red  wine  or  blueberry  wine,  toast,  butter, 

and  cold  white  meat. 
9:  00  to  10:  00  p.m.     A  cup  of  hot  peppermint-tea. 

In  mild  cases,  when  the  stool  is  of  a  pulpy  consistency, — • 
or  after  improvement  in  severe  cases, — white  bread,  carrots, 
filet,  and  baked  fish  may  be  allowed. 

Strictly  Forbidden 
Cold  drinks;    any  kind  of  coarse  vegetables,  like  cabbage 
or  potatoes;    cheese,  acids,  cakes,  coffee,  all  legumes  (except 
when  served   in  soups);    goose,   duck,   salmon,   animal   fats, 
gravies,  and  raw  fruits. 

5.  Forced=Feeding  Diet 

Indications. — Anaemia,  general  malnutrition,  atony  of  the 
stomach  (ansemic-gastroptotic  dyspepsia),  enteroptosis,  and 
pulmonary  tuberculosis. 


7: 

00 

A.AI. 

9: 

30 

A.M. 

12: 

:00 

Xoon 

3: 

:00 

P.M. 

5: 

:00 

P.M. 

352  APPENDIX 

Principle. — With  rest  in  bed,  the  patient  shoukl  be  given 
much  more  nourishment  than  he  needs  for  the  reparation  of 
tissue-waste,  in  order  to  increase  the  amount  of  adipose  tissue. 
The  diet,  therefore,  should  be  rich  in  carl)ohydrates  and  fats. 
During  the  first  two  or  three  weeks  of  the  fattening-cure,  the 
patient  shouhl  remain  in  bed  and  the  stomach  shoukl  be 
massaged  once  daily  after  the  heaviest  meal. 

One  pint  of  milk,  bread  and  butter. 

Tea  or  cocoa  with  cream,  one  piece  of  bread  and  butter, 

and  ham.     If  constipation  exists,  koumiss  and  Graham 

bread  should  be  given  instead,  with  butter. 
Vegetables    cooked    in    butter,    a    small    amount   of    meat, 

pudding  with  fruit-juice,  and  mineral  water. 
Same  as  at  7:  00  a.m. 
One  plate  of  cereal  soup  or  broth,  or  cocoa  with  cream  if  the 

bowels  are  regular. 
7:  00  P.M.        Tea  with  cream  or  milk,  white  or  whole-wheat  bread,  butter, 

two  soft  eggs  or  cold  white  meat. 

On  this  diet,  even  in  the  ambulatory  treatment,  the 
patient,  as  a  rule,  gains  two  or  three  pounds  a  week.  A  bitter 
for  the  excitation  of  the  appetite  should  alwaj^s  be  given  from 
15  to  30  minutes  before  eating. 

6.  Constipation=Diet 

Indications. — Habitual  atonic  and  spastic  constipation,  and 
mild  enterocolitis  which  runs  a  clinical  course  with  constipation. 

Contraindications. — Cardiac  disease,  habitus  apoplecticus, 
abdominal  plethora,  diseases  of  the  female  generative  organs. 

Priiiciple. — In  the  atonic  variety,  a  diet  rich  in  food- 
debris  which  chemically  and  mechanically  excites 
intestinal  peristalsis;  in  the  spastic  variety,  a  diet  non-irritating 
in  character,  which  chemically  excites  peristalsis. 

A.    DIET    IN    ATONIC    CONSTIPATION 

7 :  00  A.M.     One  glass  of  cold  water. 

7: 30  A.M.     Malt  coffee  or  tea  with  milk,  one  teaspoonful  of 

milk-sugar,  whole-wheat  bread  with  butter,  honey 

or  marmalade. 


DIETETIC  TREATMENT  353 

10:00  a.m.  Buttermilk  two  days  old,  kefir,  koumiss,  or  sour 
milk,  whole-wheat  bread,  butter  and  ham. 
12:00  to  1:00  p.m.  Vegetables,  including  cabbage,  small  amounts  of 
meat,  an  abundance  of  sweet  fruit  sauces,  and 
one  glass  of  cider  sweetened  with  one  tablespoon- 
ful  of  milk-sugar. 
4:00  p.m.      Malt    coffee  or  tea  with  milk,   whole-wheat  bread 

and  butter. 
7:00  p.m.      i  litre  of  two   days'  old  kefir  or  koumiss.  Pilsner 
beer,  bread  and  butter,  eggs  or  cold  sliced  meat. 
9:  00  to  10:  00  p.m.     Fruit  or  honey  cakes. 

Strictly  Forbidden 
Rice,  gruel,  sago  and  cereal  soups. 

B.    DIET    IN    SPASTIC    CONSTIPATION 

7:00  A.M.      One  glass  of  hot  peppermint  and  valerian  tea. 
7:30  A.M.      Tea  with  cream  and  a  tablespoonful  of  milk-sugar, 
and  fine  white  bread  with  butter  and  raspberry 

jelly. 

10:00  A.M.      Koumiss  or  kefir   two  days  old,   white   bread   and 
butter,  and  one  egg. 
12:00  to     1:00  p.m.      One  small  plate  of  soup,  tender  vegetables  cooked 
in  butter,  meat,  stewed  fruits,  and  one  glass  of 
raspberry  lemonade. 
4:  00  P.M.     Same  as  7:  30  a.m. 
6:  00  p.m.      \  litre  of  kefir  or  koumiss. 
7:00  to    8:00  p.m.      Tea  with  cream,   one  tablespoonful  of  milk-sugar, 

white  bread,  butter,  and  cold  meat. 
9:  00  to  10:  00  p.m.      Puree  of  fruit. 

Forbidden 

Cabbage,  coarse  bread,  goose,  duck,  and  all  raw  fruits, — 
except  sweet  apples,  oranges  and  grapes. 

7.  Obesity=Diet 

Indication. — Obesity. 

Principle. — Small  amounts  of  fats  and  carbohydrates, 
a  liberal  supply  of  proteids,  and  muscular  exercise.  Four 
meals  daily: 

23 


354  APPENDIX 

7:00  A.M.        One  gfass  of  foUl  water,  if  constipation  exists;  gym- 
nastic exercises. 

8:00  .\.M.        Coffee  with  a  small  amount  of  milk,   ^  pound  of 

lean  roast  beef,  some  toast  and  cheese. 
12:00  Xoon      Green  vegetables  cooked  w'ith  salt,  lean  ^•eal  and 
beef,     sour     salads, — such     as     cucumber, — red 
whortleberries,  and  one  glass  of  cider. 

4:00  P.M.        One  cup  of  coffee  with  milk,  toasted  whole-wheat 
bread  with  plum  sauce  or  cheese. 
7: 00  to    8:00  p.m.        Beef-steak   or   other   lean   meat,  1   or   2   pieces   of 
toast,  or  2  tablcspoonfuls  of  baked  potatoes,  tea 
with  lemon,  or  1  glass  of  Pilsner  beer. 

Forbidden 
Fats,  rice,  farinaceous  food,  hot  breads  and  potatoes. 

8.  Diabetes=Diet 

The  amount  of  carbohydrates  allowed  depends  upon  the 
severity  of  the  disease.  Under  no  circumstances  should  all 
carbohydrates  be  excluded,  since  otherwise  acidosis  and  dia- 
betic coma  would  develop.  I  allow,  in  all  cases,  small  amounts 
of  toast,,  baked  potatoes,  and  green  vegetables. 

7:00  A.M.      One  teaspoonful  of  Vichy  salts  dissolved  in  a  glass 

of  warm  water. 
8:00  A.M.      Tea  or  coffee  with  milk,  toast  with  plenty  of  butter, 

and  two  eggs. 
10:  00  A.M.      Cocoa  with  cream,  bouillon,  one  piece  of  toast,  butter, 

ham  or  lean  meat. 
1 :  00  P.M.     Consomme,  green  vegetables, — such  as  spinach,  peas, 

carrots,    asparagus,    Brussels    sprouts,   sauerkraut, 
'         cabbage   cooked    in    butter,    meat    of    all    kinds, 

salads  and  one  glass  of  wine. 
3:  00  P.M.      One  teaspoonful  of  bicarbonate  of  soda. 
4:  00  P.M.      Same  as  at  8:  00  a.m. 
7:00  P.M.      Tea,  cream,  butter,  cold  meat   or  filet,  chicken  and 

fish. 
9:  00  to  10:  00  p.m.      One  teaspoonful  of  bicarbonate  of  soda. 

Strictly  Forbidden 
Bread,    potatoes    (unless    baked),    rice,    grits,    noodles, 
macaroni,   farinaceous   foods,   milk,   sugar,   honey,   cake   and 
legumes. 


DIETETIC  TREATMENT  355 

9.  Qout=Diet 

Forbidden. — All  raw  meats  and  the  glandular  organs, 
such  as  the  liver,  thymus,  spleen,  lungs,  etc.,  in  order  to  avoid 
the  formation  of  the  purin  bodies. 

Allowed.— Q\i\Q.kQn,  squab,  veal,  lean  fish,  milk,  carbo- 
hydrates in  every  form,  fruit  and  vegetables. 

10.  Nutrient  Enemata 

Indications. — Corrosive  strictures,  malignant  atresia  of 
the  oesophagus  and  pylorus,  severe  ulcers  of  the  stomach, 
hyperemesis  in  pregnancy,  and  hysterical  vomiting. 

Method  of  Employment. — An  enema  of  the  following 
composition,  recommended  by  Boas,  should  be  given  three 
times  daily,  preceded  by  a  cleansing  enema: 

250  c.c.  of  milk;  1  or  2  yolks  of  eggs;  1  tablespoonful  of 
white  flour;  1  to  2  tablespoonfuls  of  red  wine;  1  knifepoint 
of  salt;   6  to  8  drops  of  tincture  of  opium. 

The  nutrient  enema  is  best  given  with  a  Naunyn  rectal 
tube,  connected  with  a  glass  funnel. 


356  APPENDIX 

Outline  of  Balneotherapy 

The  choice  of  a  suitable  health-resort  is  one  of  the  most 
difficult  tasks  of  the  physician.  If  patients  woultl  take  the 
time  and  money  for  a  trip  to  a  suitable  place  of  this  kind,  they 
would  at  least  obtain  some  beneficial  results.  If,  for  any 
reason,  an  aggravation  of  the  symptoms  of  the  disease  should 
occur,  the  attending  physician  is  usually  held  responsible. 

In  the  choice  of  a  resort  there  are  so  many  factors 
involved, — such  as  expense,  distance,  attractions,  the  divergent 
interests  of  the  different  members  of  the  family,  etc., — that 
advice  is  sometimes  very  difficult.  For  example,  if  the  hus- 
band has  acid  gastritis  and  the  wife  neurasthenia,  there  is 
nothing  to  do  but  send  them  both  to  some  quiet  summer 
resort,  where  the  husband  may  have  access  to  a  suitable 
mineral  water. 

In  the  following,  we  can  touch  only  upon  the  principles 
that  will  assist  the  physician  in  selecting  a  resort  most  likely 
to  prove  satisfactory  to  the  patient. 

The  details  and  routine  of  the  treatment  should  always 
be  left  to  the  resident  physician. 

A.    ORGANIC    DISEASES    OF    THE    STOMACH    AND    INTESTINE 

1.  Carlsbad,  Neuenahr,  Vichy,  Bertrich,  Franzensbad, 
Marienhad,  Elster  or  Tarasp  [Buffalo  Lithia  Springs,  West 
Virginia,  Crab  Orchard,  Kentucky],  the  waters  of  which  contain 
principally  sodium  bicarbonate  and  sodium  sulphate. 

Indications. — Acid  gastritis,  ulcer  of  the  stomach,  all 
forms  of  hyperchlorhydria,  gastrosuccorrhoea,  perigastritis, 
cholelithiasis,  cholecystitis,  enlargement  of  the  liver,  catarrhal 
icterus,  diabetes,  and  enterocolitis  when  the  gastric  juice  has 
a  normal  acidity  or  hyperacidity. 

Contraindications.  —  Ectasia,  carcinoma,  subacid  and 
anacid  gastritis. 

Special  Indications. — Obese  or  vigorous  persons  should 
always  be  sent  to  Marienbad,  Tarasp  or  Carlsbad;  emaciated 
patients   to   Vichy;    and   those    who   are   at   the   same   time 


BALNEOTHERAPY  357 

nervous, — particularly  women, — to  Bertrich  or  Franzensbad; 
while  Neucnahr  is  the  most  suitable  for  diabetics. 

2.  Kissingen  (Rakoczy,  Spring),  Homhurg  {Elizabeth 
Spring),  Wiesbaden  (Kochbrunner) ,  Ems,  Pyrmoni,  and  Baden- 
Baden  [Cha7npion,  Congress,  and  Hawthorn  Springs,  Saratoga, 
New  York,  and  Blue  Lick  Springs,  Kentucky],  the  waters  of 
which  contain  sodium  chloride  as  their  principal  mineral 
ingredient. 

Indications. — Subacid  or  anacid  gastritis,  catarrh  of  the 
small  and  large  intestines  when  the  gastric  juice  has  a  sub- 
acidity  or  anacidity,  chronic  constipation  (on  account  of  the 
carbon  dioxide  baths),  and  hemorrhoids. 

Special  Indications. — Kissingen  is  recommended  for 
patients  with  hemorrhoids  and  constipation;  Homburg  is 
more  suitable  for  those  with  gastritis;  Wiesbaden  for  cases 
of  enteritis  with  a  tendency  toward  diarrhoea;  while  Pyrmont 
is  best  adapted  for  very  anaemic  and  nervous  patients. 

Contraindications. — Hyperchlorhydria,  ulceration,  car- 
cinoma, ectasia,  neurasthenia  and  hysteria. 

3.  Marienbad,  the  waters  of  which  contain  sulphate  of 
magnesium  and  sulphate  of  sodium. 

Indications.— Ohesiij  associated  with  constipation. 

4.  Franzensbad,  Pistyan,  Nenndorf,  Polzin,  or  Muskau, 
for  mud-baths  used  in  conjunction  with  the  local  application 
of  hot  mud-poultices. 

Indications. — Chronic  appendicitis,  perigastritis,  and 
circumscribed  peritonitis. 

If  the  drinking  of  some  other  spring  water  is  indicated 
during  a  residence  at  one  of  these  resorts,  a  bottled  water, 
such  as  Carlsbad,  may  be  prescribed. 

5.  Flinsberg,  Pyrmont,  Franzensbad  {Eger  Salts  Spring) 
[or  Sharon  Chalybeate  Springs,  New  York,  Schuyler  Chalybeate 
Springs,  Illinois,  New  Almada  Vichy,  California],  the  waters  of 
which  are  rich  in  iron. 

Indications. — The  after-treatment  in  diseases  of  the  gastro- 
intestinal tract,  associated  with  chlorosis  and  other  anaemic 
conditions. 


358  APPENDIX 

B.    FUNCTIONAL  DISEASES   OF   THE   STOMACH   AND   INTESTINE 

General  Indications 

Patients  with  enervated  and  relaxed  nervous  sj'stems 
should  be  sent  to  the  seashore  or  to  the  high  mountains. 

Well-nourished  individuals  should  be  sent  to  the  North 
Sea,  and  ana?mic  women  and  children  to  the  Baltic, — especially 
to  those  resorts  surrounded  by  forests. 

Patients  with  marked  irritability  of  the  nervous  system 
should  be  sent  to  mountain  ranges  of  only  moderately  high 
altitude. 

1.  Westerland,  Norderney,  Borkum,  Eiigadin,  Berner 
Oherland. 

Indications. — For  individuals  who  have  become  enervated 
and  over-worked,  such  as  bankers,  physicians,  lawyers,  etc. 

2.  Kolherg,  Swinemiinde,  Rilgen,  Zoypot,  Warnemilnde, 
Haupten,  etc. 

Indications. — For  anaemic,  emaciated  patients, — especi- 
ally women  and  children. 

Patients  with  increased  reflex  irritability  of  the  nervous 
system  should  be  sent  to  some  quiet  resort  in  a  forest,  with 
an  elevation  of  from  1000  to  1500  feet.  Schreiberhau  and 
other  resorts  situated  at  the  foot  of  the  Riesen  Mountains 
fulfil  these  conditions,  as  do  also  Oberbayern,  Thiiringen, 
Harz,  and  the  resorts  in  the  middle  of  the  Black  Forest;  as 
well  as  Genfersee,  where  the  grape-cure  is  given,  and  Abbazia. 

For  many  diseases  of  the  stomach  and  intestine,  a  vaca- 
tion in  the  country  or  in  the  forest,  combined  with  a  simple 
outdoor  life,  is  all  that  is  required. 


INDICATIONS  FOR  TREATMENT  359 

Indications  for  Hydrotherapeutic,  Mechanical 
and  Electrical  Treatments 

Hydrotherapy 

Cold  Procedures. — Sea  bathing,  fresh-water  bathing, 
cold  wet  packs,  friction,  half-baths,  the  Scotch  douche,  and 
carbon  dioxide  baths. 

Indications. — Enteroptosis,  nervous  dyspepsia,  and  general 
neurasthenia,  with  a  relaxed  condition  of  the  nervous  system. 

Warm  Procedures. — Lukewarm  tub-baths,  pine-needle 
extract  baths  and  saline  baths. 

Indications. — Hysterical  dyspepsia  and  a  general  weakness 
of  the  nervous  system. 

Hot  mud-baths,  hot  mud-poultices,  hot  gruel  or  flaxseed 
poultices,  thermal  coils,  etc. 

Indications. — Chronic  inflammatory  conditions  of  the 
large  and  small  intestines,  appendicitis,  cholecystitis,  ulcer 
of  the  stomach. 

In  acute  inflammatory  conditions  of  the  stomach,  intes- 
tine, and  appendix,  without  fever, — hot,  moist  poultices  of 
chamomile,  etc. 

The  ice-bag  in  ulceration  with  hematemesis,  or  acute 
appendicitis,  with  high  fever;  and  ice-compresses  in  diffuse 
peritonitis. 

Priessnitz  moist  abdominal  bandage,  which  consists 
of  the  application  of  a  moist  towel  covered  with  oil  paper  or 
oil  silk,  bandaged  with  a  woolen  cloth,  and  worn  during  the 
night. 

Indications. — Chronic  enterocolitis,  spastic  constipation, 
and  chronic  appendicitis. 

Mechanotherapy 

Abdominal  bandages  and  supports  in  enteroptosis,  "hang- 
belly,"  or  large  hernia  of  the  linea  alba. 

The  Hantel  pessary,  in  prolapsus  of  the  anus  and 
hemorrhoids. 

Umbilical  hernia-truss,  for  small  hernia  of  the  epigastrium. 


360  APPENDIX 

Massage 

Indipations. — Heavy  massage  of  the  stomach  and  intes- 
tine is  indicated  in  atonic  conditions,  such  as  atonic  consti- 
pation, enteroptosis  and  relaxed  abdominal  walls;  light 
massage, — such  as  stroking, — in  nervous  dyspepsia,  nervous 
vomiting,  and  spastic  constipation;  and  massage  of  the  entire 
body,  in  general  relaxation  of  the  musculo-nervous  system. 

Lavage 

Indications. — Lavage  of  the  stomach  in  stasis  of  the 
gastric  contents  from  any  cause,  in  severe  dyspepsia,  for  the 
relief  of  nervous  anorexia,  vomiting,  etc. 

Irrigation  of  the  Intestine. — Lukewarm  irrigations 
are  indicated  in  atonic  constipation;  hot  irrigations  and  oil 
enemata,  in  spastic  constipation  and  catarrh  of  the  colon; 
astringent  enemata,  in  chronic  uncontrollable  diarrhoea. 

Electrotherapy 

Endofaradization  of  the  rectum  is  indicated  in  atonic 
constipation;  endogalvanization  of  the  stomach,  in  nervous 
eructations,  nervous  vomiting,  and  hysterical  disease  of  the 
stomach;  endogalvanization  (1  to  2  M.  A.)  of  the  rectum,  in 
spastic  constipation. 


CLINICAL  ABC  361 

Clinical  A  B  C  of    the  Most  Important  Disturb= 
ances  of  the  Digestive  Tract 

Chronic  Acid  Gastritis 

Pressure  in  the  stomach  after  eating  soHds,  epigastralgia 
only  in  complications.  Pyrosis.  Gastric  analysis  shows 
hyperacidity, — T.  A.  from  60  to  120. 

Carlsbad,  Vichy,  semi-solid  diet,  antacids,  belladonna. 
Smoking  forbidden. 

Subacid  Gastritis 

Pressure  in  the  stomach  after  eating  solids,  but  not  after 
liquids.  Pyrosis  absent.  Vomiting  only  after  gross  errors  in 
diet, — such  as  cheese,  cabbage  or  smoked  meats.  Tendency 
to  diarrhoea. 

Homburg,  Wiesbaden,  Kissingen,  soft  diet,  hydrochloric 
acid  and  bitters. 

Ulcer  of  the  Stomach 

The  appetite  may  be  good,  but  the  patient  is  often  afraid 
to  eat.  Epigastralgia  j  hour  to  4  hours  after  eating,  which 
is  often  relieved  by  warm  drinks,  or  vomiting  of  the  gastric 
juice.  The  localized  point  of  tenderness  in  the  epigastrium 
is  to  the  left  of  the  tenth  to  the  twelfth  dorsal  vertebrae. 

Leube's  rest  and  fasting-cure.  When  this  is  impossible, 
the  use  of  silver  nitrate  in  recent  chlorotic  ulcers,  and  bismuth 
subnitrate  in  chronic  ulcer.  Oil  for  severe  epigastralgia; 
Carlsbad  water  for  ulcer  following  acid  gastritis. 

After-Treatment. — Carlsbad  or  Vichy  water  for  six  wrecks, 
followed  by  the  milk  of  almonds  for  three  months.  In  chlo- 
rotic ulcer,  iron  spring  water. 

Cancer  of  the  Stomach 

This  occurs  in  previously  healthy  stomachs,  or  follows 
chronic  ulcer.  The  onset  is  insidious,  beginning  with  loss  of 
appetite,  repugnance  toward  meats,  anaemia  and  weakness. 

Cancer  of  the  Cardia 

Difficulty  in  swallowing,  obstruction  at  the  cardia. 


362  APPENDIX 

Cancer  of  the  Pylorus 

Stagnation  of  the  stomach-contents  with  lactic  acid 
fermentation,  or  hydrochloric  acid  present  in  carcinomatous 
degeneration  of  ulcer  of  the  pylorus. 

Extra=ostial  Carcinoma 

The  gastric  juice  is  achylous;  blood  and  pus  are  found  in 
the  fasting  stomach. 

Suitable  therapy,  either  that  of  stenosis  of  the  pylorus 
or  achylia  gastrica. 

The  treatment  of  carcinoma  of  the  pylorus  is  surgical. 

Gastrectasis 

Acute  dilatation  following  acute  paralysis  of  the  stomach, 
severe  indigestion,  or  ileus  of  the  jejunum  or  upper  ileum. 

Chronic  dilatation  is  caused  only  by  obstruction  of  the 
stomach-outlet.  Vomiting  of  stagnating  foods;  gnawing  and 
cramp-Hke  pains  in  the  epigastrium;  heartburn.  Remnants  of 
food  with  hydrochloric  acid  and  sarcinse  are  always  found  in 
the  fasting  stomach. 

Lavage,  oil-treatment,  stenosis-diet.  If  stasis  of  food 
persists  after  medical  treatment,  and  the  daily  quantity  of 
urine  secreted  is  below  500  c.c,  the  treatment  should  be 
surgical. 

Atony 
(Aneemic-Enteroptotic  Dyspepsia) 

General  ana?mia,  neurasthenia,  hysteria,  hahitus  enter- 
opticus,  and  often  tuberculosis.  Weakness,  loss  of  appetite, 
feehng  of  fulness  and  pressure  after  eating  any  kind  of  food, 
rapid  satiation  of  appetite,  regurgitation,  but  no  vomiting; 
constipation.  Secretory  and  motor  functions  of  the  stomach 
normal.  Low  position  of  the  greater  curvature  of-the  stomach. 
Loud  splashing  sounds  in  the  epigastrium. 

General,  rather  than  local  treatment,  forced  feeding  with 
rest  in  bed,  change  of  scene,  hydrotherapy,  massage,  and 
bitters.     No  special  health-resort  is  indicated. 


CLINICAL  ABC  363 

Nervous  Dyspepsia 

Secondary  to  hysteria  or  neurasthenia,  even  in  patients 
who  are  well  nourished.  Periods  of  normal  digestion  alter- 
nate with  a  constant  feeling  of  pressure  in  the  epigastrium. 
Objectively,  the  stomach  is  normal.  There  is  frequently  a 
disturbance  in  the  genito-uririary  system. 

Change  of  scene,  and  suggestion;  bromide  of  potassium 
and  valerian,  and  the  treatment  of  the  primary  disease. 

Gastric  Crises 

These  are  usually  caused  by  syphilis,  which  have  received 
insufficient  or  no  mercurial  treatment.  In  this  affection  there 
are  periodical  attacks  of  pain  and  vomiting,  following  which 
the  patient  has  a  period  of  normal  digestion.  The  symptoms 
of  tabes  are  usually  present,  although  they  sometimes  do  not 
appear  until  two  or  three  years  later. 

Treatment  should  include  morphine,  cerium  oxalate,  and 
gastric  lavage.  If  tahes  has  not  yet  positively  developed, 
inunction  treatment  with  mercury. 

Cholelithiasis 

Generally  with  obesity,  and  following  pregnancy.  There 
are  sporadically  occurring  epigastralgia, — located  principally 
on  the  right  side, — vomiting,  and  frequent  jaundice.  Fol- 
lowing the  attack,  the  patient  digests  ordinary  food  without 
trouble.  There  is  a  tendency  to  relapse,  following  errors  in 
diet  and  emotional  disturbances. 

In  an  acute  attack  the  treatment  includes  leeches,  mor- 
phine subcutaneously,  or  the  extract  of  belladonna,  and  hot 
fomentations.  In  chronic  cases  the  treatment  should  include 
Carlsbad  water,  Neuenahr,  Vichy,  or  Bertrich  at  these  places, 
or  the  water  used  at  home;    olive  oil,  chologen  or  eunatrol. 

The  treatment  is  also  surgical. 

Angina  Pectoris 

Arteriosclerosis,  myocarditis,  cramp-like  pain  after  over- 
loading the  stomach  or  after  violent  physical  exercise, — the 


364  APPENDIX 

pain   being   behind   the   sternum   and   in   the   cardiac   region, 
radiating  into  the  left  arm. 

The  treatment  shouhl  consist  of  rest,  iodide  of  potassium, 
nitroglycerin  and  diuretin. 

Nervous  and  Reflex  Vomiting 

This  is  variousl}'  caused  by  retroflexion  of  the  uterus, 
masturbation,  helminthiasis  in  children,  bronchitis,  or  emo- 
tional disturbances.  Vomiting  follows  immediately  or  within 
10  or  15  minutes  after  eating.  It  is  independent  of  the  quality 
of  food  eaten.  There  is  no  pain.  The  secretion  and  motihty 
of  the  stomach  are  normal. 

The  treatments  most  effective  are  suggestion,  mild  mas- 
sage, and  bromide  of  potassium  and  valerian. 

Catarrh  of  the  Small  Intestine 

Caused  by  repeated  indigestion  or  gastritis.  There  is  a 
feeling  of  fulness  and  distention  in  the  entire  abdomen,  espe- 
cially around  the  umbilicus,  after  excesses  in  eating,  and  often 
in  the  morning  before  breakfast.  There  is  much  flatulence, 
which  is  relieved  by  the  escape  of  gas.  Generally  the  colon 
is  simultaneously  inflamed.  The  stool  is  of  a  semi-solid  con- 
sistency, or  alternately  hard  and  semi-solid,  or  often  of  a 
liquid  consistency.  In  shght  catarrh  of  the  small  intestine, 
the  stools  often  present  no  objective  findings.  Microscopical 
findings  are  fat-needles  and  free  starch-cells. 

Catarrh  of  the  Colon 

This  is  most  frequently  caused  by  over-loading  the  diges- 
tive tract,  and  constipation  of  several  years'  standing. 

a.  Slight  Cases. — Constipation  with  membranous  enteritis. 

h.  Moderately  Severe  Cases. — Alternating  constipation 
and  diarrhoea,  with  shreds  of  mucus  in  the  stool. 

c.  Severe  Cases. — Persistent  pulpy  or  liquid  stools  con- 
taining much  mucus. 

Therapy 

a.  Laxative  mineral  water,  mild  constipation-diet,  Priess- 
nitz  compresses,  belladonna. 


CLINICAL  ABC  365 

b.  Bland  diet,  hot  mineral  water  in  small  doses. 

c.  Constipating  diet,  tannocol,  etc.,  hot  compresses,  hot 
enemata  of  a  solution  of  tannin  or  of  Carlsbad  water. 

Atonic  Constipation 

Insufficient  amounts  of  food  on  account  of  anorexia  or 
disturbances  of  the  stomach,  enteroptosis,  etc.  The  only 
symptom  is  constipation.  The  stool  is  of  large  caliber;  the 
sigmoid  flexure  is  well- filled  with  faeces;  laxatives  and  enemata 
are  effective. 

A  heavy  diet,  rich  in  cellulose,  strychnine,  cold  hydro- 
therapeutic  treatments,  massage  and  endofaradization. 

Spastic  Constipation 

The  result  of  atonic  constipation,  especially  in  neuro- 
pathic individuals.  Laxatives  and  enemata  ineffective. 
Feeling  of  tension  and  cutting  pains  in  the  abdomen.  Stools 
of  small  cahber,  surrounded  by  membranous  mucus.  The 
sigmoid  flexure  is  palpated  as  a  contracted,  painful  cord. 

Hot  apphcations,  belladonna,  oil  enemata,  mild  diet, 
and  hot  aromatic  teas. 

Typlilitis 

Pain   in   the   ileocsecal   region,    generally    diarrhoea,    and 
gurgling  sounds  in  the  right  iliac  fossa;    fever  rare. 
Hot  compresses. 

Appendicitis 

Diffuse  pain  and  the  presence  of  a  diffuse,  painful  tumor. 
Generally  fever.     No  diarrhoea. 
Ice-bag,  opium,  operation. 

Peritonitis 

Tympanites.  The  shghtest  movement, — especially  cough- 
ing and  urinating,— excrutiatingly  painful.  Fever.  Constant 
gnawing  and  cutting  pains  in  the  abdomen. 

Ice-compresses,  opium,  operation. 


366  APPENDIX 

Stenosis  and  Obstruction  of  the  Intestine 

Intonnittont  pains,  resembling  labor  pains.  No  fever, 
or  not  until  late.  T3'mpanitcs.  Vomiting.  Fecal  vomiting. 
Enemata  ineffective. 

If  pain  is  absent,  and  there  is  only  a  simple  temporary 
constipation, — laxatives.  If  colic  exists,  large  doses  of  bella- 
donna, or  the  subcutaneous  use  of  atropine  and  high  oil 
enemata.  If  medicinal  treatment  is  ineffective, — operation. 
The  uterus,  rectum  and  abdominal  rings  should  be  carefully 
examined. 

Hemorrhoids 

At  first,  lead-  and  opium-water  compresses,  followed 
by  hamamelis  per  rectum  and  mouth. 

After-Treatment. — That  of  habitual  constipation, — Hom- 
burg,  Kissingen,  etc.  (see  above). 


INDEX 


ABC,  clinical,  301 
Abdomen,  auscultation,  21 

inspection,  5 

palpation,  8 

pendulous,  190 

percussion,  8 
Abdominal  bandage,  191,  193 
Achylia  gastrica,  22,  93,  220,  223 
Acidity,  qualitative  estimation,  23 

quantitative  estimation,  25 
Acids,  combined  bydrochloric,  26 

free  hydrochloric,  26 

lactic,  23 

organic,  26 

phosphates,  26 

total,  26 
Acoria,  218 

treatment,  218 
Adhesive  plaster  abdominal  belt,  193 
Alimentation,  forced,  351 
Alkalies,  indications  for  use,  199 
Almonds,  milk  of,  124 
Aloin  blood  test,  41 
AmcEba  in  gastric  contents,  38 
Anacidity,  29 

nerA^ous,  19 
Anaemia  and  disorders  of  digestion,  223 

pernicious,  and  achylia  gastrica,  223 
Ansemic-gastroptotic  dyspepsia,  181 
Anamnesis,  1 
Angina  pectoris.  111,  228 
Ankylostomiasis,  330 
Anorexia,  nervous,  215,  217 
etiology,  217 
treatment,  218 
Anus,  335 

erosions,  335 

fissures,  335 
Appendicitis,  275 

catarrhal,  278 

diagnosis,  276 

etiology,  276 

gangrenous,  278 

larvata,  278 

recurrent,  278 

suppurative,  278 

surgical  indications,  280 

symptoms,  276 

treatment,  279 
Appendix,  palpation,  20,  244 
Ascarides,  327 
Atony,  180 


Atony  of  intestine,  321 

of  stomach,  180 
Atrophy  of  gastric  glands,  29 
Auscultation  in  diseases  of  digestion,  21 

Bacilli,  lactic  acid,  41 

Balneological  treatment  of  atrophic  gastritis, 
103 
of  chronic  gastritis,  104 
of  constipation,  313 
of  enterocolitis,  263 
of  gastric  ulcer,  121 
of  hyperacid  gastritis,  101 
of  pyloric  stenosis,  101 
Balneotherapy,  outlines,  356 
Belladonna,  use  of,  in  acute  enteritis,  85 
Belloc's  mastication  tablets,  100 
Benzidin  occult  blood  test,  252 
Bergmann's  mastication  tablets,  100 
Bilirubin  test,  Schmidt's,  252 
Blood  in  gastric  contents,  38 
tests,  aloin,  41 

benzidin.  252 
Boas-Ewald  test-breakfast,  21 

pressure  point  in  gastric  ulcer,  21 
rennin  test,  30 
sound  palpation,  13 
Bougie,  (Esophageal,  Trousseau's,  50 
Breakfast,  test-,  Boas-Ewald,  21 
Bronchitis,  relation  to  stomach,  229 
Bulimia,  216 

treatment,  217 

Caecum,  palpation  of,  20 
Caloric  value  of  foods,  82 
Carcinoma  of  cardia,  137 
symptoms,  141 

of  oesophagus,  48 

of  rectum,  341 

of  stomach,  133 
Carcinomatous  degeneration  of  ulcer,  118,  136 
Cardiospasm,  61 

diagnosis,  62 

dilator,  64 

nervous,  221 

symptoms,  61 

treatment,  63 
Carminatives,  269 
Catarrh,  82 

of  intestine,  253 
acute,  253 
chronic,  257 

367 


368 


INDEX 


Catarrh  of  rectum,  330 

of  stomach,  82 
Chlorosis  and  dyspepsia,  224 

and  peptic  ulcer,  223 
Cholelithiasis;  1 15,  234 

treatment,  234 
Cicatrix  of  duodemini,  117 

of  pylorus,  1 1 7 
Circulatory  system  and  diseases  of  digestion, 

228 
Cirrhosis  pylori,  41 
Colic,  intestinal,  78 
lead,  302,  322 
mucous,  2()(),  305 
Colitis  (see  Enteritis),  membranous,  305,  324 
Colon,  7,  16 

diseases,  253,  257 
palpation,  16 
position,  7,  17 
"  stiffenings,  "  8 
U-form,  19 
Congo-paper  test  for  HCl,  23 
Constipation,  299 
atonic,  304 
diet,  310 
treatment,  308 
catarrhal,  305 

diagnosis  of  different  stages,  306 
etiology,  300 
prognosis,  315 
prophylaxis,  315 
relation  to  diarrhoea,  318 
spastic,  305 
diet,  313 
treatment,  311 
Corsets,  use  of,  in  enteroptosis,  192 
Creosote-tincture,  197 
Cynorexia,  216 

Deglutition  murmurs,  51 
Diabetes  diet,  354 

Diarrhoea  (see  Enteritis),  ner^'ous,  323 
relation  to  constipation,  318 
stercoral,  306 
Diet  in  constipation,  atonic,  310,  352 

spastic,  313,  353 
diabetes,  354 
diarrhoea,  351 
enteritis,  acute,  255 
enterocolitis,  chronic,  262 
flatulent  intestinal  dyspepsia,  269 
forced  feeding,  351 
gastritis,  acute,  86,  349 

chronic,  97 

hyperacid,  98 

stenotic,  104,  348 

subacid,  97 
gout,  355 
intestinal  obstruction,  294 

ulcer,  275 


Diet  in  nervous  dyspepsia,  204 
obesity,  353 
oesophagus,  cancer  of,  53 

ulcer  of,  56 
peritonitis,  298 
pyloric  stenosis,  161 
stomach  cancer,  144 
dilatation,  161 
stenosis,  pylorus,  103 
ulcer,  119.  3.50 
Dietetic  outlines.  348 
Dilatation  of  intestine,  285 
of  oesophagus.  60 
of  stomach,  151 
Dilator,  cardiospasm.  64 
Distention  of  stomach,  methods,  13,  143 
Diverticulum  of  oesophagus,  61,  64 
Duodenum   ulcer,  272 

Ectasia  of  stomach  (see  Dilatation),  151 

traumatic,  165 
Electrotherapy,  360 
Enema,  nutritive,  119,  355 
Enteritis,  253 
acute,  253 

diagnosis,  255 
diet,  255 
etiology,  253 
prognosis,  256 
symptoms,  254 
treatment,  255 
chronic  (see  Enterocolitis),  257 
diagnosis,  259 
diet,  262 
etiology,  257 
prognosis,  265 
symptoms,  258 
treatment,  261 
membranous,  265,  305,  324 
Enterocolitis,  257 
Enteroptosis.  6,  190,  283 
diagnosis,  284 
general,  283 
partial,  284 
treatment,  191,  284 
Enteroptotic  dyspepsia,  180 

hygienic  treatment,  187 
medicinal  treatment,  189 
Epigastralgia,  diagnostic  significance,  77 
Epigastric  hernia,  20,  150 
Epigastrium,  palpation,  9 
Erosions,  335 

of  rectum,  335 
of  stomach,  127 

complications,  129 
diagnosis,  129 
etiology,  128 
symptoms,  128 
treatment,  129 
Ewald-Boas  test-breakfast,  21 


INDEX 


369 


Faeces  (see  Stool),  238 
examination,  245 
Fat   cells   and   droplets   in   gastric    contents 

39 
Fatty  acid  crystals,  39 
Feeding,  forced,  351 
Ferment  tests,  29 
pepsin,  32 
rennin,  30 
Fissures  of  rectum  (see  Rectum),  335 

of  stomach  (see  Stomach),  127 
Flatulence,  266 
Flatulent  dyspepsia,  266 
diagnosis,  268 
treatment,  268 
diet,  269 
medicinal,  269 
Fleiner's  oil  treatment  in  constipation,  312 
Foods,  artificially  prepared,  146 

caloric  value  of,  82 
Foreign  bodies  in  oesophagus,  67 

treatment,  67 
Functional  diseases  of  intestine,  319 
of  stomach,  177 

Gall-bladder  dyspepsia,  231 
Gastralgokenosis,  216 

treatment,  217 
Gastrectasis  (see  Dilatation),  151 
acute,  160 
chronic,  152 
Gastric  crises,  169,  226 
glands,  atrophy,  29 
juice,  acidity,  27 

component  parts,  26 
ferments,  29 

pepsin  test,  32 
rennin  test,  30 
qualitative  examination,  23 
quantitative  examination,  25 
Topfer's  method,  28 
Gastritis,  acute,  83 

diagnosis,  84 
diet,  86 
etiology,  83 
prognosis,  84 
symptoms,  83 
treatment,  84 
chronic,  87 

atrophic,  92 

treatment,  99 
classification,  88 
diagnosis,  94 
diet,  97 
etiology,  89 
hyperacid,  92,  99, 
primary,  89 
prognosis,  93 
secondary,  90,  103 
stenotic,  96 
24 


Gastritis,  chronic,  subacid,  92 
symptoms,  91 
treatment,  90 
Gastrodiaphany,  13 
Gastroptosis,  190 
Gastroptotic  dyspepsia,  180 
diagnosis,  184 
differential  diagnosis,  184 
prognosis,  185 
symptoms,  181 
treatment,  187 
diet,  187 
massage,  190 
medicinal,  189 
Gastrosuccorrhcea  (see  Hypersecretion),  168 
Genito-urinary  diseases  and  dyspepsia,  224 
Glc^nard's  disease  (see  Enteroptosis),  190 
Gout  and  dyspepsia,  224 
diet  in,  355 

Habitus  enteropticus,  6 

normal,  6 
Hang-belly,  190 

Heart  disease  and  dyspepsia,  228 
Hemorrhage,  gastric,  125 

treatment,  125 
Hemorrhoids,  337 

complications,  341 
diagnosis,  338 
prognosis,  341 
symptoms,  337 
treatment,  338 
Hernia,  epigastric,  20,  150 
diagnosis,  150 
symptoms,  150 
treatment,  151 
Hour-glass  stomach,  117 
Hydrochloric  acid,  clinical  significance,  29 
combined,  26 
congo-paper  test,  23 
free,  26 

qualitative  estimation,  23 
quantitative  estimation,  25 
Topfer's  method  of  estimating,  28 
Hydrotherapeutics,  186 
Hydrotherapy  outlines,  356 
Hyperacidity,  170 
nervous,  219 
treatment,  220 
Hyperaesthesia  of  skin  in  diseases  of  abdomen, 

21 
Hyperchlorhydria,  172 

in  acute  gastritis,  172 
in  constipation,  174 
in  neurasthenia,   174 
in  stenosis  of  pylorus,  173 
in  ulcer,  173 
prognosis,  175 
treatment,  176 
Hypersecretion,  168,  220,  221 


370 


INDEX 


HiTJersecretion,  diagnosis,  170 

symptoms,  109 

treatment,  170 
Hysteria,  liypersesthesia  of  skin  of  abdomen, 
21    ' 

(Esophageal  spasm,  70 

Ileus,  290 

Infectious  diseases  and  dyspepsia.  225 
Infusoria  in  gastric  contents,  38 
Intestine,  atony,  321 
colic,  IIG 
dilatation,  285 
diseases,  237 

anamnesis,  242 

etiology,  238 

examination,  physical,  243 

sjTnptomatology,  241 
displacements,  283 

acquired,  283 

congenital,  283 
enteritis,  acute,  253 
enterocolitis,  chronic,  257 
flatulent  dyspepsia,  266 
neurasthenia,  324 

treatment,  325 
neuroses,  319 
obstruction,  289 

diagnosis,  290 

diet,  294 

etiology,  289 

sjTnptoms,  290 

treatment,  293 
palpation,  16 
parasites,  325 
peristaltic  unrest,  8,  323 
relation  to  stomach  diseases,  235 
spasms,  321 

symptoms,  321 

treatment,  322 
stenosis,  285 

diagnosis,  287 

etiology,  286 

symptoms,  286 

treatment,  288 
"  stiffenings,  "  8,  323 
tumors,  281 
ulceration,  271 

diagnosis,  272 

diet,  275 

etiology,  272 

prognosis,  275 

treatment,  275 

Jaworski's  nuclei,  37 

Kidney,  displacements,  7,  16,  191 

palpation,  15 
Kronig's  treatment  of  corrosion  of  a:sopha- 
gus,  57 


Lab  ferment,  test  for,  30 

zymogen,  32 
Laboratory  equipment,  46 
Lactic  acid,  23 

bacilli,  41 

tests,  Kelling's  modilication  of  Uffel- 
mann's,  24 
Strauss's,  24 
Lavage,  indications,  100,  103,  360 
Laxatives,  311 
Lead  colic,  302,  322 
Leube's  ulcer  diet,  119 
Leucocytes  in  gastric  contents,  .39 
Liver,  displacements,  7 
palpation,  14 
relation  to  dyspepsia,  231 
Lungs,  relation  to  dyspepsia,  229 

Manometer  for  treatment  of  cardiospasm,  64 
Massage,  stomach,  190,  3G0 
Mathieu-Rcmond  motility  test,  35 
Mechanotherapy  outlines,  359 
Membranous  colitis,  305,  324 
Menstruation,  effect  of,  on  gastric  secretion, 

46 
Metabolism  and  dyspepsia,  223 
Meteorism,  266,  292,  323 
Microscopic  examination  of  fa?ces,  249 

of  gastric  contents,  36 
Milk  of  almonds,  124 

Motor    functions    of    stomach,     disturbances 
(see  Dilatation  of  stomach),  72 
tests,  Mathieu-Rdmond's,  35 
test  dinner,  35 
test  supper,  35 
Mucous  colic,  266.  305 
Mucus  in  gastric  contents,  40 
Murmurs,  deglutition,  51 
Muscle  fibres  in  gastric  contents,  significance, 

40 
Myasthenia  of  stomach,  ISO 
Myelin  spirals,  38 

Nephroptosis,  190 
Nervous  diarrhcra,  323 

diseases  of  rectum,  345 
dyspepsia,  199 

diagnosis,  202 

diet,  204 

etiology,  200 

prognosis,  204 

sjTuptoms,  201 

treatment,  204 
eructation,  69 
hyperacidity,  176 
system  and  dyspepsia,  225 
vomiting,  210 

diagnosis,  210 

prognosis,  212 

symptoms,  210 


INDEX 


371 


Nervous  vomiting,  treatment,  212 
Neurasthenia,  intestinal,  324 
Neuroses,  intestine,  319 

oesophagus,  68 

rectum,  345 

stomach,  209 
Nuclei,  Jaworski's,  37 
Nutritive  enema,  119 

Obesity  and  dyspepsia,  224 

Obrastzow's  method  of  palpation  of  stomach, 

11 
Obstipation,  299 
Obstruction  of  bowel,  289 
Occult  hemorrhage  tests,  aloin,  41 

benzidin,  252 
OEsophageal  bougie.  Trousseau's.  50 
CEsophagoscope,  67 
Qllsophagus,  cancer,  48 

complications,  51 
diagnosis,  49 
diet,  53 
sjrmptoms,  49 
treatment,  51 
deglutition  murmurs,  51 
dilatation,  60 

treatment,  60 
diverticulum,  60,  64, 
diagnosis,  64 
treatment,  64 
foreign  bodies  in,  67 
hypersesthesia,  69 
neuroses,  68 
stenosis,  spastic,  68 
diagnosis,  58 
treatment,  58 
stricture,  57 

etiology,  57 
symptoms,  57 
treatment,  57 
ulcer,  56 

symptoms,  56 
treatment,  56 
Oil-treatment,  53,  122,  130,  312 
Oppler-Boas  bacilli,  41 
Outlines  of  balneotherapy,  356 
of  dietetics,  348 
of  hydrotherapy,  359 
of  mechanotherapy,  359 
Ox-hunger  (see  Cynorexia),  216 
Oxyurides,  327 

Palpation  of  epigastrium,  8 

of  intestine,  16 

of  kidney,  15 

of  liver,  14 

of  rectum,  21 

of  stomach,  9 
Pancreas  and  diseases  of  digestion,  231 
Parasites  of  intestine,  249,  325 


Parasites  of  intestine,  diagnosis,  326 

treatment,  327 
Pepsin  tests,  Ilammerschlag's,  32 

clinical  value,  34 
Percussion  of  abdomen,  8 
Perforation  of  stomacli,  116 

treatment,  117 
Perigastritis,  117,  167 
diagnosis,  167 
etiology,  167 
prognosis,  167 
symptoms,  167 
treatment,  168 
Peristalsis,  visible,  of  colon,  8 
of  intestine,  8 
of  stomach,  8 
Peristaltic  unrest  of  intestine,  323 
Peritonitis,  acute,  294 
chronic,  297 
circumscribed,  296 
diet,  298 
diffuse,  296 
etiology,  294 
localized,  295 
treatment,  297 
Phthisical  dyspepsia,  196 
symptoms,  196 
treatment,  196 
Physical   examination    in    diseases    of   diges- 
tion, auscultation,  21 
inspection,  5 
palpation,  8 
percussion,  8 
Pin-worms,  327 
Proctitis,  331 
Psychotherapy,  206 
Pus  in  gastric  contents,  38 
Pylorus,  cancer,  139 
cirrhosis,  41 
hypertrophy,  103 
palpation,  13 
spasm,  117 

nervous,  221 
stenosis,  103 

treatment,  104 

Rectum,  cancer,  341 

complications,  344 

diagnosis,  342 

prognosis,  343 

symptoms,  342 

treatment,  343 
catarrh,  331 
erosion,  335 
fissure,  335 

diagnosis,  335 

etiology,  335 

symptoms,  335 

treatment,  336 
inflammation,  331 


372 


INDEX 


Rectum,  inflammation,  diagnosis,  332 
etiology,  331 
■    symptoms,  331 
treatipent,  332 
neoplasms,  337 
neuroses,  345 
stenosis,  344 

diagnosis,  344 
symptoms,  344 
treatment,  344 
ulceration,  334 

diagnosis,  334 
etiology,  335 
symptoms,  334 
treatment,  335 
Regurgitation,  79 

nervous,  210,  212 
Reichmann's  disease,  108 
Remnant    test   of   Matlueu-R(5mond,  35 
Rennin  test  of  Boas,  30 

clinical  value,  31 
Rhodankalium    reaction    of    saliva,    96 
Riegel's  test-dinner,  35 

Rose's   adhesive-plaster   abdominal  belt,   193 
Rumination,  79 

SarcinK,    presence    of,    in    gastric    contents, 

39 
Seat-worms,  327 

Sexual  organs  and  dyspepsia,  236 
Skin,  hyperaesthesia  of,  in  cliolelithiasis,  21 
in  hysteria,  21 

in    inflammation   of  abdominal   vis- 
cera, 21 
in  nervous  dyspepsia,  21 
in  ulcer  of  stomach,  21 
Sodium  hydrate  solutions,  25 
Spasm  of  cardia,  61 
of  intestine,  321 
of  pylorus,  117 
of  rectum,  345 
Splashing  sounds  in  stomach,  74,  156 
Spleen,  displacement,  7 
palpation,  13 
relation  to  dyspepsia,  231 
Stagnation  of  food  in  stomach,  40 
Stenosis  of  intestine,  285 
of  oesophagus,  58 
of  pylorus,  151 

congenital  hypertrophic,  163 
spastic,  166 
Stomach,  71 
atony,  180 
carcinoma,  133 

classification,  137 
clinical  course,  143 
complications,  143 
diagnosis,  136 
etiology,  133 
lactic  acid  in,  136 


Stomach,  carcinoma,  symptoms,  134 
treatment,  144 
cardiospasm,  01 

symptoms,  61 
determining     borders     of,      methods,  11 
dilatation,  151 
distention    with    elTervescent    mixtures, 

13 
erosions,  127 
ferments,  pepsin,  32 

rennin,  30 
fissures,  127 

etiology,  128 
symptoms,  128 
functional  diseases,  177 
diagnosis,  179 
etiology,  177 
prognosis,  179 
treatment,  180 
gastrodiaphany,  13 
hemorrhage,  125 

treatment,  125 
hour-glass  contraction,  117 
microscopic  examination,  36 
motility  tests,  remnant  test  of  Mathieu- 
Rdmond,  35 
test-dinner,  35 
test-supper,  35 
miotor  functions,  72 
neuroses,  209 
palpation,  11 
perforation,  116 
position,  11 
"  stiff enings,"  8 
subacidity,  nervous,  219 
-tube,  42 

indications  and  contraindications  in 

use,  44 
technic  in  use,  42 
ulcer,  108 

complications,  116 
diagnosis,  114 
diet,  119 
etiology,  108 
symptoms,  110 
treatment,  119 
Stool,  normal,  238 

chemical  examination.  252 
macroscopical  examination,  245 
blood,  246 
color,  245 
concrements,  248 
consistency,  246 
food  remnants,  246 
form,  245 
microscopical  examination.  249 
Surgery  of  carcinoma  of  stomach,  146 
of  dilatation  of  stomach,  162 
of  perforation  of  stomach,  117 
of  stenosis  of  pylorus.  162 


INDEX 


373 


Tabes  dorsalis,  gastric  crises  in,    169 
Tapeworm,  328 

complications,  330 

contraindications    in    treatment,    329 

diagnosis,  326 

treatment,  328 
Test-meals, 

Boas-Ewald  test-breakfast,  21 

test-dinner,  35 

test-supper,  35 
Tetany,  156 

Thiosinamin,  use  of,  289 
Tongue,  significance  of  coating,  8,  80 
Topfer's     method     of     determining     gastric 

acidity,  28 
Traumata,  role  of,  in  diseases  of  stomach,  133 
Trichoeephaliasis,  330 
Trousseau's  oesophageal  bougie,  50 
Tuberculosis,  dyspepsia  in,  196 
Tumors,  abdominal  localization,  7 

of  cardia,  141 

of  intestine,  281 
diagnosis,  281 
treatment,  282 

of  stomach,  136 
diagnosis,  136 
Typhlitis,  275 

acute,  277 

chronic,  279 

diagnosis,  276 
etiology,  276 


Typhlitis,  chronic,  surgical  indications,  280 
symptoms,  270 
treatment,  279 

Ulcer  of  duodenum.  114 
symptoms,  114 
of  intestine,  271 
of  oesophagus,  56 
of  rectum,  334 
of  stomach,  108 
Urine,  diminution  of,   in  dilatation  of  stom- 
ach, 156 

Vertigo,  gastric,  214 

treatment,  215 
Vomiting,    diagnostic   significance    of,    78 

cerebral,  225 

in  bronchitis,  229 

in  gastric  crises,  226 

in  migraine,  226 

juvenile,  211 

nervous,  210 

reflex,  210 

Worms,    intestinal,  325 
ascarides,  327 
oxyurides,  327 
seat-,  327 
tape-,  328 

Yeast  cells  in  gastric  contents,  39 


